Context

In the almost four years that Just Above Sunset has been on line the topic of healthcare has come up almost twenty times. The topic bubbles up now and then because it is a matter public policy, and for most Americans, personal. The costs keep rising, employers are playing less and less and employees more. And for what? The World Heath Organization rates healthcare in the United States rather low - France most recently had the best system in the world. We have approximately forty-four million uninsured, a rather high morbidity rate, a rather high rate of infant mortality, and we spend the most per capita on healthcare. What up with that? Could it have to do with for-profit providers and administrators, a private systems lightly regulated by the government, and a tradition of health insurance provided only by employers? It is somewhat a free-market approach. We have decided the government has no business in running a "single-payer" system, supported by taxpayers, that assures every citizen can get access to medical care. We trust to market forces and "freedom to choose" - if people want care and will pay for it, the vendors will compete for their dollars, offering more and more and better and better care, at lower and lower cost, as they compete with each other for those dollars. Well, it's a theory, or, more precisely, and ideology.

But we have a mixed-mode system. The government provides Medicare for those for whom the system has no answers, the poor and unemployed and elderly (and Wal-Mart workers). The government takes care of veterans. And hospital emergency rooms and regional trauma centers are required by law to treat whoever walks in, or is rolled in, regardless of their ability to pay for immediate, necessary treatment. Of course, the latest issue is Medicare Part D - the government covering the cost medications for the poor and unemployed and elderly (and Wal-Mart workers). That program is not going well - so complex no one much can understand how to use it, designed to protect and boost the profits of the pharmaceutical industry, not bad for the HMO's, absurdly expensive for the government, and driving even Texas pharmacies into bankruptcy - but not the topic here.

Here the topic is the whole idea of just who pays for what. Everyone chips in for the national defense, and for roads and such (infrastructure), for police and fire services. We, alone among all the nations in the industrialized world, don't seem to want to move healthcare into this category of "basic stuff the government does for the common good paid from general funds." We like the market model, with exceptions we make grudgingly. We're not getting our money's worth, given the statistical results, and cars built in the United States cost GM and Ford around fourteen hundred dollars more per unit, to cover employee and retiree health insurance, but that's just the way it is. We prefer that to "big government" running things, or even just collecting and administering the funding. We've made our choice.

Other countries have made other choices. From April 17, 2005 see Healthcare in America is the Best? - looking at our system, the one in France, the one in the UK, and a few others. From October 2, 2005 see The Nation's Health - Our Man in London, Mike McCahill, on how their system is working there. From July 10, 2005 see Oh, Canada! - on the cost of building cars here and in Southwestern Ontario, where a whole lot of "American cars" are actually built.

And the topic is in the media right now. See The Health Care Crisis and What to Do About It - Paul Krugman and Robin Wells in the March 23rd New York Review of Books, making the case for a health-care system that is not only "single payer" - the government handles the finances - but is pretty much "single provider," with the government supplying the services directly.

The counterargument to that appear in the Washington Post, Friday, March 17th, from Michael Kinsley - To Your Health: Why Modest Reform Is Preferable To Single-Payer Health Care (also posted at SLATE.COM and syndicated widely) –

Krugman and his co-author, Robin Wells, correctly diagnose the problem with the Bush administration's pet health-care solution of encouraging people (with tax breaks, naturally) to pay for routine care à la carte instead of through insurance. Like Willie Sutton in reverse, this notion goes where the money isn't. Annual checkups and sore throats aren't bankrupting us: It's the gargantuan cost of treating people who are seriously ill. People who can get insurance against that risk would be insane not to, and the government would be insane to encourage them not to.

Most lucky Americans with good insurance are doubly isolated from financial reality. They don't pay for their health care and they don't even pay for most of their insurance—their employers or the government pays. Of course, one perversity of the current system is that you can lose your insurance either by losing your job if you've got one or by taking a job (and losing Medicaid) if you don't.

The argument that follows is "let's not go so fast" - this is pretty radical.

The Washington Monthly (Kevin Drum) here says this "sure gets tiresome sometimes" –

... various forms of single-payer have been in use in dozens of advanced countries for decades - including Medicare right here in the United States. There are few social programs we know more about than single-payer, and what we know is that in a well constructed program costs are lower, the quality of healthcare is better, the amount of healthcare is higher, private healthcare remains available to anyone who wants to pay for it, and people are generally far more satisfied than American healthcare consumers are. The problems Kinsley tries to scare us with flatly don't exist in the simplistic ways he presents them, and it's dishonest for him to pretend otherwise.

Well, keeping us scared is the current mode of governance in use these days. We're used to being scared. Terrorists? Universal healthcare? Whatever. (Drum also points to others commenting here and here.)

The Canadian Experience

One reader, Ross Mallov, has much to say about their system of universal healthcare, call it Canadian Medicare, and how it works in contrast to ours. Ross Mallov, by the way, is a dual citizen of the United States and Canada. He has lived in Canada since very early childhood, and attended university in Halifax, Nova Scotia.

Here's the real story –

There are several reasons why Canadians cling to Medicare.

In the sixties, there was a lot of fuss. But afterwards, it worked well! There were actually more resources because Parliament allocated money for it. It was both compassionate and sensible for everyone, so it constituted progress - pure, undiluted progress. I think there was a tremendous amount of national patting ourselves on the back, especially since the US did not do it - it became a part of the Canadian identity.

It is hard to make Americans see the tremendous freedom of entering the doctor's office, paying only with your health card, not forms, no reimbursement, without a thought of cost. Maybe this leads to irresponsibility - I don't know.

The system worked pretty well into the early nineties. Then troubles started. Health care demand soared, as in the whole first world. Immigration brought millions of people, making even more demand. In a diabolical bit of completely false economy, provinces listened to a bunch of idiots who said we had a "doctor surplus" (according to statistics at the time, Canada had fewer per 100,000 than the US and most of Western Europe), and cut medical school enrollments at a time when demand, remember, was soaring. This has failed to prevent rising health costs, too. And surprise, surprise - people without family doctors will go straight to hospital - making care less smooth, and surely in fact more costly.

In Nova Scotia where I am, the province's restrictions on doctors' freedoms led doctors to leave for Ontario or the States. In Truro, before this happened, a doctor was prevented from settling there by other doctors who didn't want competition (what happened to their selfless commitment to professional freedom?) - several of those God damned doctors afterwards left for the States, leaving the rest of us in the lurch. There went money used by the province to train and pay them.

My current experiences are mixed - I have a good doctor at my university health service . Doctors and nurses do their best generally with insufficient resources - Halifax's hospitals provide care of such quality, even delivered with a smile most of the time. But I waited several months for a colonoscopy, and only that because my community is fortunate to have such a doctor - if I'd been in Halifax at the time, it would have been more than a year. Then I waited several months for a rheumatology appointment. Neither of these cases was urgent, but both were painful. The Regional Health Authorities are often quite bureaucratic - after the Halifax one refused to provide another colonoscopy room, one of the gastroenterologists left for Ontario. Except for MRI's, there is no private health care available in NS like in Québec or Ontario. I am having trouble getting back to a gastroenterologist, too, and a lot of intestinal pain from my misgrown large intestine hurts me daily. I do not see how the poor benefit from my misery. Inevitably priorities mean that most people who will die without care get it decently quickly, occasionally not, but any non-urgent cases have fantastic waits (hip replacements!)

Much as I hate to admit it, I would be better off in the US, although a number would not. Canadians are as selfish and complacent in some ways as Americans - many well people do not care if others must wait for months in pain, and figure they're okay and will be okay. Also, I think we cling to Medicare because in other areas, Canada is not really an equitable society - it ranks just above Britain and the USA for poverty.

Cancer survival rates are similar to the US. The life expectancy is high, but it is not in itself adequate proof of a quality system - perhaps Canadians aren't quite as portly on average. But I bet the population as a whole is healthier because of a universal system. What good is it if two more in ten thousand survive cancer if people die from completely preventable diseases for lack of ability to pay - thousands a year by the US feds' estimate? However, that would yield a strange situation in which the Canadian population is healthier, but the average Canadian has poorer care than the average American.

My mother's family hoped her brother would be born after 1 Jan 1959, when the hospital insurance act came into effect, but he wasn't. And she grew up and spent her young-adult years in Medicare's glory days, so she still deeply believes in it. But I and a growing number of Canadians believe that it must be possible to avoid monstrous waiting lists without denying one in seven health insurance and letting middle class families' finances be ruined by cancer. France's system stems demand probably unfairly, especially on the poor, by co-payments that do not vary with income. However, they have managed to avoid the British situation's dualism of public-private quality and cost. On a website for Britons moving to France, I saw -"Comparing private and public hospitals in France to the same in the UK is like comparing apples and oranges. There is no difference in the quality of care between public and private hospitals, and there is not necessarily any great difference in price."

I am quite jealous of this French feat, particularly since, if I got cancer there for example, all costs would be covered. Excellent - quick curative care and financial security too would clearly leave both Canada and the US in the dust. France has been accused of maintaining well-funded hospitals by over-focusing on curative and hospital care at the expense of community and preventative care - don't know how fare this is true. France also has great flexibility - you can go to a specialist directly, and now you must pay for it yourself, but that's only fair. In Canada, you can have as much choice as is now possible, but not that - gatekeeping and rationing for short supply are necessary, and while freedom of choice for family doctor was never purposely eliminated (this was AMA propaganda), it has become effectively quite rare since a number of people cannot even have a family doctor.

It should be noted that, just as Republicans rant about public health care, many of the people who helped hurt Canada's system did so by treating it as just another budget problem, not as a public INSURANCE plan - many of these are Republicans' own ideological counterparts, such as Ralph Klein, and Mike Harris in Ontario's "common sense revolution" (Ha!)

Confusion also results when Americans try to fit our politics into the left-right boxes of American politics (or vice versa) - political systems are not quite equivalent. However, this is in some ways a good thing, because Canada and the US are of similar origin, but turned out differently - each represents what the other could have been. However, I think we both should look beyond each other, toward Europe and Australia as well.

A well-thought paper on the Swedish system noted that if some patients go private, not only can they make themselves better off, but they actually shorten the list for those in the public queue. This could help. However, if not carefully regulated, a private system could poach scarce resources from the public system, denying availability to these physicians except at a high price. I wonder if this happens in the UK or New Zealand - it would probably happen in Canada if allowed, where the real problem is not enough doctors and nurses.

This is pretty accurate, I hope you'll find. I used to be a passionate supporter of Medicare on principle, but my own illness has forced me to look more practically , so I'm not an ideologue. What I'm saying is the truth, the WHOLE truth, and nothing but the truth, so help me God.

And he adds this –

You should realize that I have never been to France, so I do not have first-hand knowledge of their system. However, all sources that I have read say that France, with a few exceptions, has no waiting list problem. To me, this sounds better than the current American system. In France, people who have certain serious diseases (there is an official list) have one hundred percent of conventional medical bills covered (although some extra billing is possible, I believe, if a doctor charges more than the usual fee, the tarif conventionné). In the US, even good insurance does not provide any such security. In an article (I can't remember where it was), the author remarked that part of the focus should be on how American health insurance is not only bad for those with no insurance, but also is bad for ordinary Middle America, which can face financial ruin if medical bills exceed catastrophic medical expense coverage.

My paragraph about my family wasn't that clear. In case it was incomprehensible, I'll explain. My grandmother was pregnant with my uncle in December 1958. They were very poor, and I believe had no health insurance. (Even in the sixties, although costs were much lower, a far greater percentage of Canadians lacked health insurance then than lack health insurance now in the US).

They were hoping that she wouldn't give birth until Jan 1 1959, when general hospital insurance took effect. However, my uncle was born in December, so he had to be born at home. Also, when I said that Parliament allocated more resources for it, I meant that Parliament allocated money to expand medical facilities etc. when Medicare came in.

In recent developments, in the last few years, provinces have upped medical school enrollments. I am not sure what effect that will have, since those medical students will not become full doctors for a bit.

I am not sure if you wanted to know this, but I'm trying to round out what I said earlier.

So there you have it. What they have up north kind of works. And what we have down here?

The two countries are so much alike - my two years working in London, Ontario was a breeze and quite comfortable, and I have only fine memories of the good, slyly funny, just decent people who became my friends there. But there were differences - there wasn't much free-market right-wing ideology, nor much or the left - just an effort to get what was going on and do the best for everyone concerned. The aggression and pushiness was confined to the London Knights minor league hockey games. And this is the country that gave us curling (men with brooms).

There's much to consider here.