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POLICY: Oh Canada, implications for the US, part 1

Medpundit has written an article over at Techcentralstation basically saying that Canadian doctors hate the system there and are leaving for the US.  I’ve responded briefly in the comments there, but am working on a much longer piece that will explain that in general Canadians are happier with their health care system than are Americans, get as good or better care at a much cheaper cost to society in a much more equitable system, and that the few Canadian doctors who are leaving are doing it for the money and to escape that terrible winter.

While you are waiting with bated breath for that intellectual feast, to introduce the notion I’m linking to an email debate between two major players in the health policy wonk world, Steffi Wollhandler and Ken Thorpe. Steffi has argued for a Canadian-style single payer for years. Ken, who was an under-secretary of HHS under Clinton, argues for essentially a redux of Clinton’s plan–which despite much BS talked at the time–was not a single payer plan as they both make clear.

Personally speaking, either one of these reform solutions would be better than what we have now. But in this blog I’m tying to forecast what I think will happen not what I want to happen.  So while you’re pondering the merits of the debate, in considering its relevance you may notice that:

a) this debate is happening in the Newark Ledger-Journal,  not the New York Times. This is not an insult to the fine people of the Ledger-Journal, but it’s scarcely the first source for news and information for most Americans.

b) two left of center, politically-active health care wonks are finding plenty to disagree on, and stress very little the  common ground they share opposing the current system–scarcely the makings of the national consensus that would be required for health care reform. Note that such consensus was not built properly by the Clintons in 1993-4.

c) Health care reform that doesn’t in some way get the doctors, the pharmas, and the insurers to buy-in/be bribed-in is very unlikely to happen–definitely not with a Republican house. So if you are watching for it, you need to see a Democratic President, massive public discontent (which is building but not there yet), and a unified vision of what problems need to be fixed and a "good enough" solution to fix them.  My guess is that the most identifiable "problems" are uninsurance and out of pocket cost control.  Neither administrative costs (Steffi’s bugbear) nor care coordination (Ken’s concern) are likely to get the public’s passion raised enough to get reform underway.

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3 replies »

  1. I am an American MD and a former WK Kellogg Fellow at Harvard. Before that, I went to train in internal medicine and in clinical immunology at McGill’s Faculty of Medicine. I did so to learn about the universal single payer plans in Canada.
    I think that one cannot compare the systems in the USA and Canada very easily. Canada is a pluralistic and engaged society, so one can find a whole range of opinions on their own health care system. Canadian doctors and patients clearly identify with their system and maintain it even though they naturally want it to be better.
    Some malcontents leave for the USA. Let us face it some doctors simply want to move where they can make more money. Are we better for their coming here? Canadians generally do not know as much about America as they think that they do. So the grass looks greener for them south of the border when they compare salaries on a dollar for dollar basis. But life is different here.
    The bottom line is that the Canadian system works very well. It is by no means perfect. There is a social contract there and we have much to learn from them. I would challenge any American who is skeptical about the Canadian health care system to go up there and spend some time there. For physicians mix with their MDs. For patients, meet up with citizens there. For taxpayers compare costs, etc.
    I am very tired of American arrogance and our inability to give credit to other people for thei successes.
    Canadians are different from us temperamentally.
    Our health care system has deteriorated because of our many perverse incentives and mercenary attitudes. You cannot build a univeral system on the basis of procedure oriented and profiting subspecialists. You cannot easily implement a universal health care plan upon a system profiting from these perverse incentives. Doctors and technology/pharmaceutical companies run a health care system. Their constructive participation cannot be taken for granted and their behavior can easily destroy well meaning reforms.
    I could write for hours on this subject but I have not posted here and so will wait for response first.
    Bohdan A. Oryshkevich, MD, MPH
    New York City
    bao23@columbia.edu

  2. Steven is correct, each province is a single payor. No one can be turned away, typically province bill one another for patients that cross borders (athough this is discouraged). While no one goes without health care there are certainly large disparities in the quality of care delivered in each province relative to the economic prosperity of each province. Healthcare is funded from a variety of taxes both federal and provincial. In Alberta the majority of the funding comes from taxs on resources (oil) since there is no provincial sales tax. There is a federal sales tax of 6% that basically goes into general revenue for the federal govt.

  3. There are several points that are never discussed in these forums, that are important for the general public to know if they are going to take part in the debate as informed participants. Few people including the “experts” realize Canada does not have a national single payor plan, they have a provincial single payor plan. Here in the US are we willing to let NY pay for New Yorkers and Louisiana pay for themselves? If so how long before the poorer states in the union cry poverty and call for the richer states to pay for their shortfall. Why does’nt anyone talk about how healthcare is paid for in Canada. Yes they do have a much higher income tax than the US, but that does not pay for their healthcare, they have an 8% sales tax for health insurance on top of the 7-8% provincial sales tax, thats right, 15% sales tax, on every restaurant bill, pair of shoes, automobile etc..

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