As a former Canadian citizen, I can tell you that Canada still has a universal health care system and it is still much harder to get into medical school there than it is in America. The amount of Canadians in US/Caribbean medical schools is quite overrepresented. Canadian doctors make less than what we do, but the exodus that you would consider hasn't happened. In fact, the opposite is true - many people want to practice there, but there are major restrictions in doing so. As far as health care there, until the late 80s - early 90s, there wasn't many complaints about the Canadian system. Excellent primary care, excellent specialty care, good outcomes, universal access, happy physicians. Why? Because the system was and is structurally sound - when it was funded, it worked. Like any enterprise, if you don't fund it, it won't work.
In the early mid 1990s when Ottawa ran out of money, there was a mass exodus of Canadian health care workers into the states. This includes all levels of medical field workers from physicians to physicists. The reason: taxes, wages and working conditions. It created a temporary glut on the US market making jobs appear scarcer than reality and leading to forcasts of physician surpluses in the states. At the same time, the provinces began contracting with border facilitites to handle patients they could not, or Canadians of means were crossing the border on their own dime (or should I say toonie) to get care outside the provincial system. Ottawa got it going, created a tonne of new taxes and when it cost too much dumped it to the provinces. The maritimes got screwed and the western provinces struggled. This was the gist of a meeting of First Ministers at Dalhousie in the summer of 2002. You have wisely noted this in your comment.
While the concept of universal health care is appealing and none of us wants to see human suffering and loss of dignity, the simple fact remains that there is an opportunity cost to everything. If I choose to work for top dollar and gamble that I am healthy and don't need health insurance and I don't get sick, I win. But when I have the first twinges of chest pain from eating McDeathburgers every night, then it is too late, and I lose.
A far right government, a populace that became more 'individualistic'/American-minded, and they starved the system. Of course it doesn't work now! They spend far less than us, so it can't work.
Precisely. Yet, did the Clark government reduce the taxes they put in place? Did Mulrooney or Cretien reduce the taxes when they starved the system? Of course not. It was underfunded, from the outset and when it starting becoming clear, it was dumped on the provinces who couldn't afford it either. The simple fact remains that health care costs resources which must be either forgone or paid for. Resources are finite, and free resources are infinitely demanded. TANSTAAFL!
The reason our system seems to work is because we fund it better. And by this I mean in sum total - we make less wages so our companies can provide us gold-plated health plans ($1400 of the money from the sale of one car produced by the big 3 goes towards health care),
True. If you want quality and availability someone has to pay for it. I was at a lecture when an auto exec-VP made this exact statement. Now, let's do some math, shall we.
Price of New Car: $27,000 (average)
Price of Health Care ~ 15% of GDP.
Automakers cost of health care as a percentage of asking price: 5%
Who's paying the other 10%? Why isn't Ford paying its fair share? And does this amortization include workers comp medical costs from OTJ injuries? I'll bet it does. Probably includes FMLA and workers comp premiums and even their workers health benefits analyst salaries (fully burdened, of course).
(i.e. we treat whole brain radiation in 10 fractions, when major studies show non-inferiority compared to 5 fractions). However, physician salaries are a pittance compared to the rest of the waste. We pay a lot more, we get a little more, without necessarily better results.
Careful here, this is a highly controversial area. When we palliate whole brain in RPA III patients, you might just have a point, but Loeffler, DeAngelis and others have also demonstrated that there is significantly increased morbidity with higher dose/fraction schemes. At elevated fractions above 3 Gy/fraction, up to 6 Gy/fraction autopsy and imaging studies show there are significant bad things happening in radiated brains in longer term survivors. Since many times WBRT is given to hospice appropriate patients in palliation and survival is measured in less than 6 months, you have a small point, but this does not illustrate waste.
A better example is the AMI patient who is given ASA, qD post cath and then given Celebrex for the chronic arthritis when ASA can do the same job for both at a couple of bucks a month instead of $60. Is there waste? Of course. There's waste in everything. But a free and open market eventually will bring waste to a minimum while maximizing performance. At least in Smith's theory.
Study the Canadian system in the 70s, the Nordic models of the same era - it's a beautiful example of the private and public sector joining together to provide a service at a high level and a low cost. If you take the money out of any enterprise, it will not work.
And that is the problem with both the American socialized medicine and the Canadian, British and others. We all want a free lunch. And it ain't there. Initially funding is plentiful, but as soon as the system comes on line, and is fully operational, unless the funding models are established to provide for the full costs, eventually any system which does not minimize costs of operation (waste, fraud, abuse, overhead) and maximize availability will fail. I should think that the economic collapse of the USSR should have amply demonstrated that Smith was a better economist than Marx. The only way to do this effectively is to allow each to make his own economic decisions, rather than have generalized decisions made for everyone else. Once generalized decisions are made, we begin to fall off the optimum market curve and become less efficient, and thus more wasteful of our collective resources.
NavCanada is a prime example of a this. It has been in existence less than a decade and already it's funding model is crumbling. But have good cheer, it will be taken out of every Canadian's hide, eventually, one way or another.
Medicare? Ask a senior citizen if they are willing to go private - you'll get punched in the teeth by some of the feistier ones if you even talk about it.
Yes, and like the Canadian system, the Sustainable Growth formula is threatening to kill the program deader than the feisty old guy that just sent you to the dentist. Medicare/CMS has huge overheads, as do the insurance companies in the private sector. But the fact remains that medicare and social security funding is fatally flawed, premised on an ever expanding population and economy and when that premise fails, you don't get paid what it costs you. And to cover the tracks, you now have to get your UPIN, hire a full time clerk for which you pay even more MC/SS taxes to fund the system, which inappropriately switches costs from one pot to another at the expense of the least powerful, the guys actually doing the work.
I'm just frustated with the knee-jerk "ALL UNIVERSAL MEDICINE IS BAD" from anyone in the world of health care.
The problem, as I see it, and I have lived and worked in the former Soviet Republics and helped rebuild economic bases following the collapse, is that once you have a single source of funding, then that source has absolute and total control over every aspect of your professional and perhaps personal life as well. This includes not just single-payer schemas, but oligo-payers as well, such as Blue Cross, Aetna, and companies. Once you are the only game in town, you are in a position to dictate 20 Gy/4 Gy/fx, even though the patient is and RPA I with a completely resected met with a life expectancy of 60 months and 30/3Gy would yield a far higher QALY.
A case report: 32 yo female with 3-4 months hx of epigastric pain uncontrolled by tagamet, otc antacids, seen by Gyn on periodic exam with a palpable pelvic mass. U/S not done because the HMO gives bonuses if you stay below a certain level of study prescriptions. 2 months later she reports to the ED with increasing abdominal distress, severe pain that wakes her up, and is diagnosed with PID, given abx and sent home because of the HMO bonus policy. No u/s. Two days later, in the gyn clinic, abx are switched. A week later she revisits the ED and this time insists on an u/s which reveals the 18 cm bilateral adenexal mass which is biopsied and found to be an ovarian carcinoma, now Stage IV. This case was at a major university, she was an employee of that university and had HMO insurance through that university. This is the problem with pre-authorization, with single payer systems and our present system.
And making it a single payer system will not make it better, but further stiffle competition which leads to excellence in care (pay for performance?) and a minimization of waste. You are indeed correct: the system is broke. And we need to fix it, but I think we need to fix it the way we fixed the airline systems in the '70s. We deregulated them and ended the monopolies. Result: More airlines, lower fares, more choice, and far more efficiently run operations using far more fuel efficient aircraft. Everybody wins. Make it all one airline, and we'll have no control, pay whatever they want and go and come when and if they say so.
