Socialised Healthcare

[Segnosaur]

There's been a publically-funded health care system in Canada for about forty years now and bureaucrats have yet to make any decisions about a patient's health care; doctors are still the only ones making such decisions.

Actually, bureaucrats (and the politicians) make decisions all the time about a patient's health care. They may not do so directly, but their impact is still felt.

For example, when the bureaucrats or politicians decide to build a new MRI machine (or set the running hours on an existing machine) they are making decisions about your health care. They aren't directly telling you what your treatment should be, but they are affecting the way your disease is treated. Under a more free-market system, the owners and/or operators of the clinic could decide to install a new machine or extend the operating hours on the old one (in an attempt to get more profit), but have no incentive to do so when there is no reward.

Or when the bureaucrats or politicians decide not to provide treatment for a disease, they are making decisions that affect you. For example, the Ontario government at one time did not provide treatment for anyone with Fabry's disease. Since that time, they've started providing treatment, but only to selected individuals... there are still government employees deciding who gets treatment and who does not.

 

[Rolfe]

It should also be noted that the U.S. system is generally ranked as the most responsive health care system (even if it is the most expensive and not everyone has equal coverage). So, here its a philosophical question... is it better to have equal access to health care (as in Canada) where everyone ends up with poor to average health care, or is it better to have an American system where there is a much wider range, but where some people will have it worse than in Canada, but the average person will have it much better?

I realised that the figures quoted by Abe the Man couldn't be right. But I'm not convinced yours are right either.

Is it really the case that in Canada everyone ends up with sigificantly poorer healthcare than the average person in America? Is it really the case that the average American (by this I assume the bulk of the population) gets "so much better" care than the Canadian standard? I have no experience of Canada, but I would need some proof of that. It sounds a bit like the statements declaring that universal healthcare would cost everyone 98% of their income!

The bugaboo in the NHS in Britain is the waiting list. People are prioritised generally according to clinical urgency, though the government has tried to manipulate that politically so it's not invariably true. However, the point is that if you need something right now, you'll get it. On the other hand if you can wait, you might have to. There is probably some incidence of avoidable deaths on waiting lists, but it's not at scandal proportions, and if it were, there are political pressures to resort to. I suspect this incidence is lower than avoidable deaths in America because people don't have insurance coverage - and there have been reports of allegedly avoidable deaths because insurance companies refused to authorise payment for certain recommended procedures. So I think it may be swings and roundabouts.

And never forget that universal healthcare doesn't remove choice. People still have the choice to fund care entirely privately, out of capital (I mentioned earlier that my elderly mother did that for eye surgery), or to buy additional insurance. So the high end doesn't disappear at all.

The difference is that in an insurance based system, while safety-net care is there for the low income, only the low income people see any benefit. Everyone else has to make other arrangements. Despite contributing to this safety-net care in their taxes. Then the mainstream system has to support a tier of insurance companies and their administration and overheads as well as the actual health care. Insurance costs are set by peceived risk, so those just above the safety net level may be paying very disproportionate slices of their income for cover. And it's all too easy for ordinary average people, perhaps affected by loss of employment or the sub-prime situation, to fall back to the safety net, which is not very good coverage as far as I understand.

So, to your philosophical question. I don't think you have the parameters right, so far as the British system is concerned. There is not equal access. If you are affluent, and want to pay for six-star treatment, either through insurance or from capital, you are entirely free to do so.

What there is, is equal access to the equivalent of the safety net, which is so much higher that it catches almost everyone to their (reasonable) satisfaction, and as a result most people are happy for that to be their entire coverage. This is accessible to everyone, regardless of income, and paid for by everyone according to their means (well, there is an upper cap on National Insurance so that after a certain point you're considered to have paid your dues and it doesn't go up any further).

I think, basically, that you're cutting off the bottom of your range in this arrangement. And some people who might be in the starrier bracket in the US system voluntarily decide to settle for the standard package, because it's seen as good value. But the top? Well, they sky's still the limit.

Rolfe.

 

[fls]

This systematic review may be of interest in making comparisons.

A systematic review of studies comparing health outcomes in Canada and the United States

Linda

 

[Rolfe]

For example, when the bureaucrats or politicians decide to build a new MRI machine (or set the running hours on an existing machine) they are making decisions about your health care. They aren't directly telling you what your treatment should be, but they are affecting the way your disease is treated. Under a more free-market system, the owners and/or operators of the clinic could decide to install a new machine or extend the operating hours on the old one (in an attempt to get more profit), but have no incentive to do so when there is no reward.

Now that is true. I often get people here saying how much better treatment they get from the vet, because they never have to wait. I point out that's because it's private healthcare, and if there was a significant waiting list then the practice would expand, or someone else would move in.

However, attempts are being made in Britain to introduce some market forces into the NHS, with varying success, to address this issue while still retaining the universal coverage. And I repeat, if there is general outrage about a certain service being restricted or unavailable, the ability of the public to exert political pressure on the single provider (the government) should not be underestimated. And again, the options of self-pay and additional insurance are still there, so the top of the market still competes for those patients.

Rolfe.

 

[Segnosaur]

It may be more useful to establish your underlying assumption, first. How do you determine whether the health care is poor to average in Canada, and whether the average person has it better in the US? The US tends to get ranked lower than the rest of the G7 countries on various measures of health/health care.

Actually, you've just provided the answer to your own question with the WHO figures.

The WHO does rank the U.S. lower than many other countries, but their ranking system includes the cost of health care (which I agree, is very expensive) and the distribution (again, I agree, contains a lot of disparity.) But if you look at the details, you'll see that the U.S. is ranked #1 in responsiveness (something I consider to be a key indicator of what the health care system actually does.)

I made no changes to the care I provided depending upon the country I was practising in ...

I'm sure you did keep things consistent. The problem is, so much is out of control of the health practitioners... after all, its not the doctors who decide to build MRI machines, or upgrade hospitals, or train other people to become doctors. Those are (for the most part) decisions that are done either through the free market and/or the government. And regardless of how dedicated a doctor is to providing health care, they will always be at the mercy of such external forces.

 

[fls]

Actually, bureaucrats (and the politicians) make decisions all the time about a patient's health care. They may not do so directly, but their impact is still felt.

For example, when the bureaucrats or politicians decide to build a new MRI machine (or set the running hours on an existing machine) they are making decisions about your health care. They aren't directly telling you what your treatment should be, but they are affecting the way your disease is treated. Under a more free-market system, the owners and/or operators of the clinic could decide to install a new machine or extend the operating hours on the old one (in an attempt to get more profit), but have no incentive to do so when there is no reward.

I agree that funding decisions can influence how care is provided. We were talking about interference in individual situations and Corsair's comment was in regards to that.

Or when the bureaucrats or politicians decide not to provide treatment for a disease, they are making decisions that affect you. For example, the Ontario government at one time did not provide treatment for anyone with Fabry's disease. Since that time, they've started providing treatment, but only to selected individuals... there are still government employees deciding who gets treatment and who does not.

A similar example is the decision about whether and when to cover Betaseron in people with Multiple Sclerosis when it first became available. But these are the exception, rather than the rule.

Linda

 

[fls]

Actually, you've just provided the answer to your own question with the WHO figures.

The WHO does rank the U.S. lower than many other countries, but their ranking system includes the cost of health care (which I agree, is very expensive) and the distribution (again, I agree, contains a lot of disparity.) But if you look at the details, you'll see that the U.S. is ranked #1 in responsiveness (something I consider to be a key indicator of what the health care system actually does.)

I have to admit that I tend to put more emphasis on hard outcomes, such as death and disability.

Linda

 

[Segnosaur]

I realised that the figures quoted by Abe the Man couldn't be right. But I'm not convinced yours are right either.

Is it really the case that in Canada everyone ends up with sigificantly poorer healthcare than the average person in America? Is it really the case that the average American (by this I assume the bulk of the population) gets "so much better" care than the Canadian standard? I have no experience of Canada, but I would need some proof of that. It sounds a bit like the statements declaring that universal healthcare would cost everyone 98% of their income!

The bugaboo in the NHS in Britain is the waiting list.

Waiting lists are also the main problem here in Canada too. Well, that and some of the diagnostic tools and/or treatments are simply not available. (Part of that is due to the fact that we have such a small population spread out over such an area that we don't have the proper economy of scale.)

There is probably some incidence of avoidable deaths on waiting lists, but it's not at scandal proportions, and if it were, there are political pressures to resort to.

Remember, there is more than just 'avoidable deaths'... there are also quality-of-life issues. If you need a hip-replacement operation, you might not die, but you're going to suffer signficantly from it.

And never forget that universal healthcare doesn't remove choice. People still have the choice to fund care entirely privately, out of capital (I mentioned earlier that my elderly mother did that for eye surgery), or to buy additional insurance.

Again, this depends on how things are run. However, Canada is probably the country which places the biggest restrictions on private health care. In most areas of the country, you're not allowed private insurance, nor are you allowed privately run hospitals.

Personally, I think a mix of private and public is the best way to go (like in most European countries). I have no particular love of the American system; however, I just don't like people automatically jumping in and saying "Private health care is bad because..." without looking at the problems in a more rigid public system.

Then the mainstream system has to support a tier of insurance companies and their administration and overheads as well as the actual health care.

Yes, the insurance companies do cause some overhead. But then, there is a great amount of overhead in a public system too. However, in a private system there is a motive for reducing overhead... namely, profits. (Yeah, insurance companies and other health care corporations are greedy b*stards, so lets use it to our advantage.) In the public system, often staffed by unionized buerocrats, there is no incentive to improve things, no incentive to cut costs or provide more service.

 

[Segnosaur]

This systematic review may be of interest in making comparisons.

A systematic review of studies comparing health outcomes in Canada and the United States

Linda

I do have a few, ahem, issues with that particular article.

First of all, its a 'meta-article'... they didn't do their own direct research, but they simply picked other articles that they thought might have been relevant. The problem is, how do we know that they didn't overlook articles (in the best case), or in the worst case, cherry-picked articles in order to prove their point? There were almost 5000 possible articles that they looked through, and they took only 38? That's less than 1%.

Secondly, not sure if I agree with the way they've ahem, analyzed their results. For example, some of the studies are measured from the time of diagnosis... yet one of the main problems with Canadian system is the length of time it takes to actually GET a diagnosis. Another example was classified as having better results for Canada, but when you actually looked at their analysis, it actually had a mixture of results (better in Canada at one stage of the disease, worse at another stage.)

(I could also point out that I'm not 100% sure of the people publishing this article; for all I know, it may be as relevant as the 'peer-reviewed' 9/11 truther journals. But it does appear that most of the editors and authors are qualified so I'll let that slide.)

 

[Ivor the Engineer]

<snip>...the options of self-pay and additional insurance are still there, so the top of the market still competes for those patients.

Rolfe.

The problem with health care is the market does not have to compete. It is a product everyone wants, often needs, and rarely can make informed choices about who to get treatment from.

In a free-market heath care system, the doctor has to split themselves in half: on the one hand they are supposed to have the patient's best interests in mind, on the other they are there to make the maximum amount of money from treating the patient.

So is medical care in the US, when you can afford to pay for it, amazing? No. Do physicians in the US provide a service better than anywhere else in the world? No.

(Given a recent first-hand account I've heard, they are just as selfish and human as the rest of us.)

BTW, let's not forget where many of the private consultants in the UK work most of the week: The NHS, where they struggle by on £47k to £110k per year. Some have to top up this meagre salary with private work on the side. What other company allows you to moonlight in this way?

My former dentist went private about 15 years ago. He is now retired in his late forties/early fifties and is funding his son through a golf academy in Florida. Nice to know my £6/month for 2 check-ups per year and the occasional visit to the hygienist got me value for money. If I had had anything wrong with my teeth, my premium would have increased to double or even three times this amount.

"Let the tall trees grow taller."

 

[Ivor the Engineer]

<snip>

However, in a private system there is a motive for reducing overhead... namely, profits. (Yeah, insurance companies and other health care corporations are greedy b*stards, so lets use it to our advantage.) In the public system, often staffed by unionized buerocrats, there is no incentive to improve things, no incentive to cut costs or provide more service.

You are assuming the market works (and can work) efficiently. Making more money can be achieved two ways: reduce costs or charge more. Which of these do you think has been happening in the US?

 

[Segnosaur]

For example, when the bureaucrats or politicians decide to build a new MRI machine (or set the running hours on an existing machine) they are making decisions about your health care.

I agree that funding decisions can influence how care is provided. We were talking about interference in individual situations and Corsair's comment was in regards to that.

Yeah, I know cases where insurance companies have dictated treatment policy have been discussed. The point I was trying to make is that while it does happen in the U.S., it does not necessarily mean that the alternative (an all-government run system) doesn't have flaws which may be just as bad (if not worse).

But if you look at the details, you'll see that the U.S. is ranked #1 in responsiveness (something I consider to be a key indicator of what the health care system actually does.)

I have to admit that I tend to put more emphasis on hard outcomes, such as death and disability.

But its the responsiveness (getting people in for treatment/diagnosis, establishing infrastructure where and when its needed) that affects death and disability rates.

 

[Segnosaur]

You are assuming the market works (and can work) efficiently.

It doesn't have to work perfectly efficiently... just more efficiently than the alternative. Comparing western economies to the Soviet economies prior to the fall of the Berlin wall should give a good indication of which model worked best for the people.

Making more money can be achieved two ways: reduce costs or charge more. Which of these do you think has been happening in the US?

If a hospital, clinic or doctor tries increasing costs excessively, what will prevent other health care providers from moving in, and charging less in order to undercut the competition?

I'd have to say that the increased cost of health care in the U.S. is likely due to 2 things:

- Higher costs of lawsuits
- Overcapacity (after all, if you want to allow immediate treatment you have to have unused resources which cost money to maintain)

 

[Rolfe]

But if you look at the details, you'll see that the U.S. is ranked #1 in responsiveness (something I consider to be a key indicator of what the health care system actually does.)

Yes, I remember reading that. Unlike you, the great responsiveness score left me underwhelmed.

Just a thought. Suppose responsiveness was speed-of-light - for 20% of the population. But the rest are caught in a system which delivers relatively little, for a lot of money. Is it worth it? How big a proportion of your population do you leave behind, and it's still worth it for the fortunate?

I think we may be in some agreement here. I'm in favour of compulsory National Insurance, premiums based on ability to pay (that is in effect tax, though in our case as I said there is a cap beyond which the very high earners stop paying any more). This funds a universal system available to everyone which delivers quailty care to a good standard. Anyone who is not satisfied with this may also purchase additional insurance, or choose to pay out of their own capital as the need arises. This is pretty much what we have.

Needs some tinkering though. The problem at the beginning is that modern medical advances weren't envisaged. Bevan thought care would get cheaper due to early intervention and improved preventative medicine. Yes that happened at one end, but at the other end, we learned to transplant hearts! I think we need to sit down and be explicit that certain very expensive interventions will not be funded. If these things get cheaper, they can always go back on the list! I'm mainly thinking very expensive drugs offering only a short life extension in terminal illness, but that's a whole other sociology debate.

At least we'd know what to insure against, or save up for, and the insurance companies could put together packages tailored to these restrictions.

We also need to get smarter when introducing efficiency measures. Recent attempts to improve value for money seem to have resulted in massive wastage in management costs. And IT blunders. Better thinking when trying to improve matters by introducing competition would be a start. But these are management issues that can and should be addressed. I cannot see that they are insuperable problems that mean we should go back to only a very minimal safety net, with the bulk of the population paying insurance according to risk. This puts far too great a burden on the relatively low paid who are above the safety net. I can't stress enough the advantage of knowing that there's nothing that can happen healthcare-wise that can bankrupt you, or even put too great a strain on the pension fund. (I omit care for the elderly here, including the demented elderly, as even in Scotland which is supposed to be Utopia in that respect, it's still a worry.)

I used to believe that the NHS and private systems should be separate. What are these consultants up to, moonlighting for BUPA while waiting lists exist?! Well, there is a bit of incentive to let a waiting list grow when you have a private practice, but it seems to be lessening (at least where my consultant friend lives). And I now see the advantage of keeping hold of the best surgeons in the NHS this way, and keeping the centres of excellence in the NHS. The way it has worked out is that lack of an NHS consultancy post is the kiss of death for a private surgeon, and if you are planning private surgery all you have to do is ask what the surgeon's NHS post is, and all will be revealed.

But God alone knows how you'd get the US from where it is now, to anything like that. As I said about ten pages ago, you have to start from where you are. What can be done?

Rolfe.

 

[Rolfe]

But its the responsiveness (getting people in for treatment/diagnosis, establishing infrastructure where and when its needed) that affects death and disability rates.

Not entirely. If responsiveness is good in emergency cases, with proiritisation according to clinical urgency, the effect may not be nearly as marked as you imply.

Remember, there is more than just 'avoidable deaths'... there are also quality-of-life issues. If you need a hip-replacement operation, you might not die, but you're going to suffer signficantly from it.

Indeed. And I reserve the right to fulminate that if a vet left a patient untreated in that state because of a waiting list he'd be prosecuted for "causing unnecessary suffering", any time I see fit. Nevertheless, there is a degree of prioritisation here as well. My cousin recently had a hip replacement very quickly, much faster than the official waiting list time. Her GP saw that she was deteriorating much faster than average, and pressed some sort of priority button. But I've also seen this fail to happen. This needs to be more widespread, but also some of the undercapacity also needs to be addressed. It's back to these failed efficiency measures - the money is there, if they succeeded.

I'm simply not convinced that it's necessary to let a substantial section of the community commit a disproportionate amount of their income to funding their healthcare, and have the threat of complete financial collapse if something goes wrong (unexpected serious illness and/or job loss), to ensure a reasonable delivery within the system. If the NHS was graced with the percentage of GDP that the USA spends on healthcare, who knows what the standards would be like? Value for money isn't everything, but it isn't nothing either.

Rolfe.

 

[Fitter]

If the US shifts to socialized "HillaryCare", where will the Canadians go for expeditious health care? Inquiring minds need to know.

Who are these Canadians going to the States for treatment? I've lived in all areas of Canada and know of only one person who has gone to the U.S. for anything medical and he was invited there by the Mayo clinic so they could do tests to help find out why he had dramatically out-lived all other recipients of an experimental treatment. Every time this debate pops up someone mentions the "fact" that large numbers of Canadians are crossing the border for rapid treatment and yet I don't know any of them. Can any other Canadians confirm that this actually occurs?

 

[Ivor the Engineer]

It doesn't have to work perfectly efficiently... just more efficiently than the alternative. Comparing western economies to the Soviet economies prior to the fall of the Berlin wall should give a good indication of which model worked best for the people.

I agree. For many products and services the free-market works better than planned economies. Health care is quite a unique service though, in that it is often required quickly, the consumer is usually unable to make informed choices, and it requires highly skilled providers, the supply of which are rationed by medical schools.

If a hospital, clinic or doctor tries increasing costs excessively, what will prevent other health care providers from moving in, and charging less in order to undercut the competition?

I'd have to say that the increased cost of health care in the U.S. is likely due to 2 things:

- Higher costs of lawsuits
- Overcapacity (after all, if you want to allow immediate treatment you have to have unused resources which cost money to maintain)

While I agree your first point certainly has an impact on the cost of medical care, the second is bizarre.

In how many other markets when there is overcapacity does the price increase? If I flood the market with my product, the reduced demand for it should lower the price, not keep it inflated, if the market is working.

What incentive is there for physicians and other health care providers to lower their charges and/or restrict their treatment to that which is necessary? How can you decide if one treatment is better than another?

So long as people can pay more to access health care, those companies and individuals operating in a free-market system are onto a sure thing.

 

[Corsair 115]

The fact that the health care system was brought into play by a democratic government does not mean that there is not force involved. There ARE people who do not like the health care system and would want to opt-out if they could; however, under the current laws they cannot.

The same can be said for taxes going to public education. Or the military. Or to government-funded programs of various types.

At what point do you draw the line as to what individuals can opt out of paying taxes for?

As an example, if 51% of the population had the politicians pass laws to make the other 49% of the population slaves, that would not make it morally right (even if the 51% were able to get all the laws passed legally).

That's a silly analogy because there are certain rights accorded to all citizens under the Constitution and the Charter of Rights and Freedoms.

It depends... do you consider people to have property rights? Granted, in Canada we don't have those particular rights. But lets say we actually had a real constitution that actually had such property rights... forcing people to pay into a universal health care system they do not want (and to disallow private health care) is a violation of the right to use property in the way that they choose.

See first reply. The same line of argument you're using can be used against taxes used for public education, the military, government programs of different kinds, etc.

 

[fls]

I do have a few, ahem, issues with that particular article.

First of all, its a 'meta-article'... they didn't do their own direct research, but they simply picked other articles that they thought might have been relevant. The problem is, how do we know that they didn't overlook articles (in the best case), or in the worst case, cherry-picked articles in order to prove their point? There were almost 5000 possible articles that they looked through, and they took only 38? That's less than 1%.

They very thoroughly outlined how they collected and selected the articles. And they couldn't have cherry-picked, since the assessment was blinded - i.e. they didn't know in advance whether picking a particular article would support their point or contradict it.

Secondly, not sure if I agree with the way they've ahem, analyzed their results. For example, some of the studies are measured from the time of diagnosis... yet one of the main problems with Canadian system is the length of time it takes to actually GET a diagnosis. Another example was classified as having better results for Canada, but when you actually looked at their analysis, it actually had a mixture of results (better in Canada at one stage of the disease, worse at another stage.)

If it takes longer to get a diagnosis in Canada, that would actually make the US look better by introducing a lead-time bias.

(I could also point out that I'm not 100% sure of the people publishing this article; for all I know, it may be as relevant as the 'peer-reviewed' 9/11 truther journals. But it does appear that most of the editors and authors are qualified so I'll let that slide.)

That's pretty funny. If Gordon Guyatt doesn't have the chops to do this, no one does.

Linda

 

[fls]

Just off the top of my head, Canada has been innovative in a number of areas related (I think) to the health care system.

Telemedicine to provide service to remote areas.

A leader in the use of adminstrative databases to answer systemic questions.

Research and programs to increase efficiency and equality - eg. Western Canada Waiting List Project, Cardiac Care Network of Ontario, Manitoba Centre for Health Policy Research and Evaluation.

The birthplace of Evidence Based Medicine.

Linda