Canada, health care reform, and you

A few things in the health care debate have been riling my feathers lately.  The first is yesterday's post by Ezra Klein examining how the folks over at the right-leaning The Corner are busy questioning the definition of "is".    Ramesh Ponnuru writes:

I don't think [universal health care] is possible, actually. If you can't get an operation because your country's national health insurance system has you on a long waiting list, in what sense have you enjoyed "universal coverage"?

Ezra goes on to discuss how one can, in fact, define universal, and that definition is "everyone in the population receiving health insurance". 

Jon Cohn addresses the latter part of Ponnuru's argument over at The New Republic's blog, the Plank, and dug into the stats on waiting lists:

Here's the summary findings from an exhaustive survey by the Organization for Economic Cooperation and Development (OECD):

The health system in France is regarded as delivering high quality services, with freedom of choice and generally no waiting lists for treatments.
--Page 69, sourced to a 2000 study by a trio of academics

And: In Germany, "Waiting lists and explicit rationing decisions are virtually unknown."
--Page 70, citing a World Health Organization study.

If Ramesh knows something the OECD doesn't, I'd love to hear about it.

I'm going to throw myself into the fight here, and debunk another favored myth of the Right, which is that the Canadian health system is so bad, millions of Canadians come here for their health care. 

A 2002 Health Affairs paper examined hospitals near the border, as well as national surveys to tease out how many Canadians actually visit the U.S. to receive elective procedures.

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.

What angers me so much about the Right's rhetoric on health care reform is that their arguments are so weak that they're now essential questioning the definition of "is".

Universal health care has been achieved in dozens of nations on this planet.  One of which has some waiting lists, while others have essentially none.  According to surveys, less than 0.1% of Canadians are expressly seeking care in the U.S. 

The bottom line is our health care is twice as expensive, fails to cover 46 million people, has questionable quality, kills around 100,000 people a year from error, and for all this we have worse health indicators (i.e. lower life expectancy, higher infant mortality, etc).  Other countries do it better, and they do it with the help of government to pay for health costs.    

We can at least move to a system where everyone has health insurance. Or, you can believe the folks over at the Corner who are arguing that universal coverage doesn't exist.

What do you want? 

Comments

[Neil the Ethical Werewolf]

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.

The number will actually come out to be bigger than that due to our bigger population (you're working with percentages of total populations up there, not raw quantities).

Maybe the thing to say here is that Americans are 72 times more likely to get prescription drugs from Canada than Canadians are to come here for operations.

[Rebecca Allen, PhD, ARNP]

I live in Washington state. Our neighbor province of British Columbia has established a land-office business in laser eye surgery, marketing extensively to U.S. patients. I don't know the numbers, but apparently a significant number of people in this region travel to BC for their laser surgery; I gather it's cheaper (but still high-quality) up there. Waiting lists don't seem to be an issue. Funny, you don't hear the right wing talk about this either.

[Sabutai]

I think that there's a difference between getting mail-order drugs, many of which can be purchased due to pre-arranged trips and even over the Internet, and being physically present for care. The first is much easier than the other.

Part of the drive of this "Canadians come to the US" storyline is that the Canadians who do come are very prominent. The best example is Brian Mulroney, who came to Washington DC to give a speech on the superiority of the Canadian medical system, then flew down to Florida to see his doctor.

I consider myself a progressive Democrat, but I also lived in Montreal for 6 years. I remember the weekends when CTV news reported 36 hour wait times for a hospital bed to open up, or the Health Canada report I read that estimated a 13-month delay in Prairie provinces between first attempt to schedule an appointment, and first chemo treatment.

I agree that there isn't a waiting list if you stagger into an emergency ward, clutching your chest and gasping, or bleeding profusely. But 13 hours for chemo? Government-administered health care may not be a bad idea, but Canada is in no way a model.

[jpm100]

I lived in a Canadian border city and basically you're being extremely misleading.

First healthcare varies from province to province. Some provinces have a vary US-like system while others, like Ontario are heavily socialized.

The reason that Canadians don't seek healthcare in the US is that it won't be funded. Canadians won't and usually can't pay for expensive procedures like MRI's. Add they also have their state-sponsored healthcare system telling them it isn't necessary. So, they usually don't have medical insurance to cover core services since they count on the government for that. So any medical treatment outside the US is out of pocket with savings the a Canadian never meant to go to healthcare.

In my city in the 80's there was a program run that helped Canadians obtain bypass surgery in a local Detroit hospital. They convinced the Ontario government to fund their normal portion and got agreements to lower costs from Detroit medical facilities.

This was a huge political embarassment. The government pulled the funding. The rationale: The waiting list for bypass surgery grew from 4 months to 8 months and leveled off. So going outside the province was no longer necessary. (a cookie to the person who uses a little logic and realizes why the waiting list 'stabilized' when it grew from 4 months to 8 months with people in extremely poor health).

As an additional note: Canadians don't have dental or optical. They also carry supplimental insurance usually through their company. Many things you allude to by paid for are not.

Drugs are cheaper because the Canadian government will deny a drug to be sold to the public unless the drug producer sells them just above cost to make. The real cost of a drug is the R&D cost. The portion of the R&D costs that Canadians would have paid gets essentially pushed off onto the Americans who pay for cost to make + all the R&D costs for countries who make the same arrangements as Canada.

The one advantage the Canadians have in healthcare costs is that lawsuits are not as likely to win and even less likely to give big awards when they do win. You're basically suing the goverment and the whole judicial system is appointed by the goverment so most citizen vs. the government lawsuits fail. I'd imagine the insurance premiums for procedures like lazer eye surgery in the US to be fairly phenomenal while in Canada relatively small.

[paul]

Wow. Who knew that lawsuit costs of less than 3% of all health spending in the US made such a difference? And that drug marketing costs, which in the US are comparable to "R&D" costs, weren't an issue? (I say "R&D" because it is extraordinarily expensive to bring to market a newly-patented variation on an existing drug that extends the life of a monopoly but offers only a tiny increment in quality of care for patients; drugs that offer clear and convincing improvements are typically rather cheaper to study.)

Oh, and let's forget completely that the fraction of each health-care dollar spent on administration in Canada is roughly half of similar spending in the US. Couldn't possibly have any effect on costs.

Whenever I see something about waiting lists in other countries, I'm reminded that the US simply doesn't gather comparable data. All the people who can't afford decent care in the US have are on a waiting list marked "forever", but no one bothers to count them.

[Floyd]

Comparing health care costs with prescription drug costs makes no sense. You really just have just talked about one or the other, because the two function in a totally different way. As jpm100 noted, Canadians get a great deal on prescription drugs because Canada acts as a "free rider", with American spending allowing the drug companies to stay in business and profit. If full importation from Canada would be allowed to occur, the drug companies would presumably stop selling to Canada at those prices because their source of revenues would be gone. Goodbye, low drug prices.

[Floyd]

As for infant mortality: these doctors say that the idea of higher levels in the U.S. is a myth caused strictly by different standards of reporting.

[justadoc]

Need to stop discussing "costs" as such and talk about "man-hours". What "costs" money is the number of man hours it takes to deliver a good or service. To cut "costs", most universal coverage either limit the coverage (decrease the man-hours) or limit the cost per man-hour (mandate maximum pay rates). Either will wind up decreasing the amount of health care provided (some of which is unnecessary.

[Matthew Holt]

Lucky that we have genii like JPM100 to tell us that Bob Evans and Maurice Barer and their team which did the study on cross border medicine don't know squat--I mean I thought they were the two best health services resaerchers I've ever met, but what the hell did I know. I'm glad he corrected me.

And then he tells us that many provinces have a US style system. Good to know. But I'm a little surprised that the shysters at Fraser and PRI haven't found the many uninsured Canadians that must live in those forward thinking provinces and splashed their name all over the op-ed pages.

And the reason that the Ontario government pulled that program was that the costs were going out of control. One reason was that US hospitals were sending buses up to Toronto, pulling drunks off skid-row, taking them down to their hopsitals and sending the Ontario government the bill. As a responsible conservative Canadian taxpayer, I'd assume that JPM100 would be happy that the Ontario government wanted to stop that waste of its money.

[Nate Ogden]

If you do a search for French Healthcare Rationing you find numerous articles about the financial crisis the French System is in. Doctor’s striking, Physician and Nurse shortages, increasing waiting list, did you read anything outside OECD?

Why is the UK looking at implementing German style rationing to solve their crisis? It appears everyone knows more then the OECD, and it only takes a simple web search to find it. That being said I actually like the German model, in case the OECD hasn’t told you about it, studies have shown the elderly are denied expensive care that is given to younger patients, since Germany is doing it can I assume you socialist approve and we can cut Medicare spending?

In regards to your next argument what percentage of Canadians could even afford to pay for a surgery in the US? News flash…poor Canadians don’t come to the US for out of pocket surgery. Why would you look at hospitals along the border? If your rich and want the best surgery wouldn’t you go to an American Center of Excellence….few of which are along the border. It amazing the arguments you can make when you cherry pick the data. So why do Canadians that can afford to elect to have their surgeries in the US?

Could you find some older data to work with? The great thing about ponzie schemes or national healthcare is how great they work in the beginning, everyone is happy, it’s when the bill comes due down the road that they collapse. France, Germany, England, and Canada all have a financial crisis TODAY in regards to healthcare. What’s amazing is how socialist can know this and still demand we copy a failed system. Yes all of them had great systems a decade ago before they collapsed, how do we copy that without the same ending?

How many people take prescriptions versus how many have surgery, pointless to even argue that comparison.

[Joyful Alternative]

Sabutai reports: "I remember the weekends when CTV news reported 36 hour wait times for a hospital bed to open up" in Canada. This anecdote makes me snicker, because I've waited with my very sick husband on an emergency room cot for 48 hours for a hospital bed to open up here in the U.S. However, we didn't make the news.

[jrochest]

Some provinces have a vary US-like system while others, like Ontario are heavily socialized.

I gotta ask -- which provinces have a US style system? Ralphie would love to have one, but Alberta is as bound by the Canada Health Act as any other province.

[Adam Herman]

I agree for the most part, just so long as we aren't talking about a silly single-payer system like Canada's. France or Germany are the models to follow, not Canada and Britain.

Two-tiered is the way to go. People have an inalienable right to buy as much health care as they want, how they want it, if they have the means. The government should provide health care to the poor, and let everyone else handle it as they see fit.

[Alex]

Not everyone wants to live in a welfare state. Not everyone wants to import European taxes, European unemployment, and European mediocrity. Not everyone subscribes to platitudes about the moral obligation to provide health care on demand, especially from peopel who reject the notion of any other moral compass on issues. Not everyone wants a committee of the Illuminati sitting in a room deciding who gets what service. Not everyone believes that the current situation is a failure of the free market in health care.

[mikefromtexas]

'Not everyone wants a committee of the Illuminati sitting in a room deciding who gets what service.' Alex, if I didn't know better from the context of your post, I'd swear you just descibed my HMO.

[david]

Interesting post, but there may be some methodologic issues. First, the authors limited their survey to NY, Michigan, and Washington state. Since this selection omits common "medical meccas" like Mayo in MN and MD Anderson in TX, to name a few, as well as snowbird destination states like AZ, CA and FL (it is not too difficult for a Canadian facing a delay in Canada to defer treatment to a winter visit in the US), I wonder if they are missing data. Second, their data depends upon self-reporting from US hospitals, and I wonder how much effort somebody from a US hospital is going to put into making sure that these researchers got high quality data.

[der Hildebeast]

What angers me so much about the left’s rhetoric is the notion that “other countries do it better, and they do it with the help of government to pay for health costs. “

Better? Really? Which countries are the “other” countries? How do you quantify that they “do it better”?

And my all time favorite…” with the help of government to pay for health costs.” Really! Does “government” go out back and shake the money tree to pay? Maybe the tooth fairy leaves the money under Hillary’s pillow at night?

Providing health care insurance to those who are capable of providing their own but refuse to do so, for what ever reason, will be a major error in judgment by the politicians in the United States. It will encourage irresponsible behavior. It will increase costs. It will result in higher taxes. It will lower the quality of care in the United States.

[Not So Much]

i think that if you can do something about this issue, you have the right to be complaining, but if you dont move your butt past the computer, you shouldn't be whining.

[rob]

The issue is quality not quantity? The fact is that, what you pay for health care is a lot. Our taxes our high and our wait times our also long. Sure the us has great service and sure some people will come north when the dollar is good to get it cheaper but I am sure that it is at a price. less professional doctors and longer waits.

[joe transit]

Our doctors tend to travel south to get better pay and we have the less qualified doctors from other countries. When is the last time you had a doc from canada treat you and was he also trained here. We pay from there training and then they go south to the U.S.A. I have tried both systems and there are good and bad for the two systems but for us Canadians to say we have the best health care system in the world, that is just ludicris. Look at norway or some other system that have a dual type system and it works great. By the way Norway is the top country to live in. Canada is falling every year. We are now at sixth. The canadian health care system in canada is great if you never have to use it?

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