POLICY: Oh Canada

This article is about Canada’s health system and its relationship to the US health policy debate.  It is not meant to be an endorsement of Canada’s system, or an endorsement of single payer for the US. From my personal point of view, while I think serious health care reform is unlikely in the next few years in the US, some foreign models of health insurance are very useful for the US debate. But the combined local/employer insurance systems seen in Japan, Germany and Holland provide a more likely and familiar model for the US, than the Canadian or UK single-payer systems. However, this article isn’t about what might happen here or which system is better. This article is about the distortions that are frequently heard in the US, and in Canada for that matter, about the Canadian system. It’s also a lot longer than the average post, such as my recent post on Canada, Steffi and Ken, and you can download it as a separate document here if you want to print it out and savor/criticize it over a cup of coffee.

This article is dedicated to the amazing Medpundit. Despite the fact that I disagree with a huge percentage of what she says, Sydney Smith manages to cover virtually all of health care and medicine in her excellent blog, while writing book reviews, keeping up a full time solo family practice, and claiming that she’s not posting as much as she used to.  Her article on Canadian physician emigration and the vigorous support she got from her commenters finally got me to get off the dime and put in my several cents worth.

Before I jump into this it’s worth noting that some of the differences between these health care systems are cultural. There have been several interesting descriptions of the international variations in medical practices. In one great book written in the 1980s, The Painful Prescription,  Aaron and Schwartz describe rationing of hospital care in Europe and the UK compared to the US. For instance they pointed out that  in the UK kidney dialysis was not used at nearly the levels among the elderly as it was in the US (or in fact in Europe).  So they concluded that care was rationed and as a direct consequence people died. (If you have ESRD and don’t get treatment eventually your kidneys shut down and you die). However, many other commentators, including Lynn Payer in her book Medicine and Culture which is very well described by Humphrey Taylor from Harris, have shown fairly conclusively that many cultures just regard "care" in a different way. In that sense the dialysis-use figures could be seen as the aggrandizement of hundreds of decisions not to over-tax elderly patients with a long and difficult treatment that wouldn’t help their quality of life, even as it extended it slightly. Indeed, it’s equally cultural relative to accuse Americans of "over-care" by doing CABGs on 95 year olds who are soon going to die anyway. So while you’re reading the rest of this article you need to bear in mind that some of the differences that are ascribed to policy are due to culture. Having said that; many are not. 

Before we start, recall that Canada has a single payer in each province that provides uniform health insurance to all its citizens. To provide that care it contracts directly and exclusively with physicians and hospitals, who remain largely autonomous but have no other customers. The US in contrast has a mixed-private-public system for which the government provides about half the money. Insurance is only universal for those over 65, and roughly 14% of the population has no insurance coverage, with very varying levels of coverage for the rest–mostly coming through employers. The latest comparable numbers have the US spending roughly 14% of GDP on health care while that number is around 11% in Canada. So at a macro level, the Canadians pay less as a share of their income to cover more of their people. (In fact as its GDP per capita is lower than America’s Canada spends considerably less per citizen). While single-payer advocates tout those numbers, many critics claim that Canada rations care, and that both patients and physicians are leaving Canada to give and receive care that’s not available at home.

Given that, it’s worth looking at two main aspects of the Canadian system that frequently come up for criticism. How are patients doing? What’s going on with physicians? And are they really all leaving the Great White North to escape its health care system?

The Patient Experience

It’s simplistic and true to say that Canadians have free access to basic health care. Americans have varied access based mostly on insurance. And it’s accepted that, as a corollary, all Canadians have less access to high-technology health care than do most Americans, However, googling around the web you’ll find indications that 18% of Canadians cannot get access to first contact care, (although only 10% have had trouble getting routine day time care). Still even 10% lacking access to care isn’t nothing, especially in a universal insurance system.  Luckily the Commonwealth Fund has over the years funded my old colleagues at Harris and Harvard, led by Bob Blendon, to do several studies over the years about these issues.  They asked consumers’ views in several countries, but we’ll concentrate on Canada and the US. (Note: When you open a link that is a powerpoint slide, hit the page down button as there might be 2 or 3 slides in that one link)

System satisfaction: Canadians were very happy with their system in the  late 1980s but were much less happy by 1998 and also in 2001, after a period of funding reduction.  But they are still happier than Americans, or at least only 18% want to completely rebuild the system, as opposed to over 28% of Americans. (The 2003 American number is over 30%–I don’t have the latest Canadian numbers, but they have been spending increasingly more and their incoming PM has promised to maintain that level. So as satisfaction went down due to less money you can expect that level to increase when there’s more. It’s also worth noting that the Canadians saved the rest of their economy some money, while during the large boom in the US in the 1990s, the health care sector stayed steady as a share of GDP.

Access to care: In terms of actually getting care and accessing doctors, both Americans and Canadians felt access was about the same. But in terms of access to care, by 2001 26% of Canadians thought it was getting worse, and only 6% getting better. 20% of Americans thought their access was getting worse too, but 17% thought it was getting better.

But then we get to some of the key issues. In Canada for elective surgery you have to wait; two thirds of Americans can get it within a month. Most Canadians have to wait more than a month and more than 25% have waited more than 4 months. No one waits that long in the US (presumably so long as they can qualify for coverage).

Costs matter: But in the US costs really matter. Over a quarter of Americans had out-of-pocket costs of over $1,000, compared to less than 5% of Canadians. Americans were two to five times more likely than Canadians to have an access problem due to cost, such as not getting a needed drug or not seeing a doctor. And when you look at those with below average incomes, in Canada only 9% failed to get recommended follow up care due to cost. In the US, over one third did not. More than a quarter of Americans (26%)–including 39% of those with below average incomes–didn’t fill a prescription because of costs, more than twice the number than in Canada. 21% of Americans have problems paying medical bills compared to only 5% in Canada, and that goes for 35% of Americans with below average incomes. So on a macro level it’s true that nationally Canadians sacrifice getting access to expensive resources (such as MRIs and surgeons). But in turn they don’t have to put up with the individual cost issues that are a problem for many Americans, especially the poorer ones.

If you look at the same type of indicators amongst those who are sick in similar study (also from Blendon’s group)  they are virtually all the same, with problems of access to specialty care and hospitals in Canada matched by access problems due to cost being 2-3 times worse for the sick in the US. Here are the sources for the full charts for the "healthys" and the "sick".

The impatient inpatient: This is where the arguments get anecdotal, and little ridiculous. I never understand, for instance, why American small business owners who have to buy insurance in the world’s most dysfunctional market complain so much about the prospect of Canadian-style health care. In 1993 I talked to a Rotary Club where, before I even got my international comparisons slide out, the small business owners in the room came after me with the classic anti-Canadian argument that goes something like "When he needed care the Prime Minister of Alberta/Nova Scotia/Yukon Territory/Canada came down to the US". There has always been an extremely limited number of Canadians getting new high-tech care in the US that isn’t available in Canada, almost always paid for by their province.  However this has been transposed into the argument that thousands of Canadians are flooding across the border to get care that is unavailable at home.  There is even the very occasional and underfilled patient bus trip coming down to get prescriptions and treatments unavailable in Canada, of course massively outnumbered by the buses taking Americans to buy cheaper drugs up north.

While the argument about Canadians flooding south to get medical care withheld from them up north is widely heard, it’s bullshit. Yup, lots of Canadians get care in the US, but that’s because, due to the better weather, the higher incomes, going to college or that NAFTA thing, they eitherlive here, or are on vacation in Florida to escape that terrible winter. Work done by a team led by Steve Katz at University of Michigan with  the Evans/Barer/Cardiff team at UBC which looked into this in obsessive detail found essentially no evidence of Canadians crossing the border to get care. (Incidentally plenty of Americans are still going up there for non-covered surgery like laser corrective eye surgery, which is cheaper and just as good up north). In fact according to Canadian insurers there appears to be no interest amongst Canadian consumers in commercial insurance products to cover care abroad, other than standard holiday cover. Note that this is not the case in the UK, where private insurance allows about 10% of Brits to jump the queue to get surgery in a private hospital. So it looks like the Canadians accept the fact that they have to wait for surgery, and not surprisingly don’t want to come down here to pay for it out of pocket.

The Grumpy Doctors

As mentioned earlier, I started working on this article partly because Sydney Smith over at Medpundit wrote a piece saying essentially that Canadian doctors felt that their system sucked, they all wanted to move to the US and that many of them already had–leading to a doctor shortage in Canada. She concluded:

    And why are Canadian physicians leaving their patients in the lurch? Not for the money. They leave for better research opportunities, for greater professional and clinical autonomy, better job choices, and better medical facilities. They leave, in other words, for all the advantages conferred by a free-market healthcare system–the same advantages that we American physicians take for granted when we yearn for a Canadian-style system. We should look to Canada, all right, but not as a role model. We should look to them instead as a warning. There but for the grace of God–and a strong independent streak–go we.

Before we look more at the emigration factor, again it’s worth looking at a relatively recent study by the Harvard team. In 2000 they asked a set of questions to doctors in the same five (English-speaking nations) nations where they surveyed patients in 1998 and 2001. It was indeed true that doctors in Canada were pretty miserable, and you certainly can trawl the Internet and easily find grumpy Canadian doctors, and many anecdotal stories of them leaving for the good life in the US. In the Harvard study, Canadian doctors did believe that their ability to provide quality care had got worse in the last five years, but only slightly more Canadian doctors believed this (59% v 56% for generalists and 67% v 60% for specialists) than did Americans. And Canadians were only slightly more pessimistic that the quality of care would decline (61% v 54%) in the future. But when asked about major problems in their practice, compared to Americans they were one-third less likely to regard external review of clinical decisions to control costs as a problem (13% v 36%), and less than one-half as likely to see limitations on drugs they could prescribe (18% v 43%), or to be concerned that their patients couldn’t afford necessary prescription drugs (17% v 48%). These of course are the typical hassles that make up the drudgery of a physician’s daily practice. The real concerns of Canadian physicians compared to Americans were, of course, limitations on specialist referrals (66% v 29%) and access to hospital care (64% v 8%) for their patients.

Then things get really interesting.  When asked, more directly if their actual patients often lacked access to newest drugs or medical technology only 26% of Canadian doctors said so–roughly the same as the 27% of Americans. And when asked if their patients get sicker because they are not able to get the health care they need, instead of the high numbers you might expect, only 12% of Canadian doctors said so, as opposed to 18% of Americans. So it appears that Canadian physicians think that by and large that Canadian patients do actually get the care they need, or if they don’t, it seems not to impact their health.

Then when asked about their satisfaction with their own practice 72% were very or somewhat satisfied compared to 68% of Americans.  And when you ask the classic three Harris questions about satisfaction with the system and the need for reform, Canadian docs are much less likely to want "complete rebuilding" (4% vs 12%), and similarly much more likely (25% vs 16%) to think that their system "works well." Here is the full physician chart set.

There’s no question that Canadian doctors are less happy than they were, but that’s more to do with the funding (and pay) cuts they saw over the previous decade (which were a symptom of the Canadian government getting its health care spending under control) than anything fundamentally wrong with the system.

The dissatisfied disappearing physician. But what about all those Canadian doctors fleeing the country? Well let’s first look at why they are fleeing. There are several Canadian researchers or specialists in the US taking advantage of bigger budgets for their research, or training in something Canada leaves to its bigger, richer neighbor. A 1994 survey of Canadian physicians living in the United States found that postgraduate training in the United States was associated with subsequent emigration–in other words they went there, they liked it and stayed or went back later. Other reasons for staying in the US included professional/clinical autonomy, availability of medical facilities and jobs, and remuneration, although this last factor was curiously considered equally important by Canada-based docs as a reason for staying behind. (They clearly hadn’t asked their √©migr√© colleagues what they were making!)

Now we’re starting to get somewhere. Just as Canada takes advantage of America’s over abundance of facilities to buy high-tech services for its patients on the margin (usually before it later adopts them in its own facilities) it also does the same for doctors who want to work in highly-specialized cutting edge technology areas. As in many other industries, the opportunities to do the coolest stuff tend to be here in the States. For an example, look to this somewhat tongue-in-cheek debate between Robert Califf, a Duke cardiologist and a Canadian colleague David Naylor which asked if American cardiac care is better than Canadian care?

By now you know the answer. If as a patient or a cardiologist you make it to Duke (or another high-end American institution), you find quicker access to more expensive technologies.

    Califf noted  that Americans experienced "differences in mortality over time largely because of the difference in the rate of revascularization between the countries"  Conversely, "simply stated, for people with heart disease, the US offers greater access, better technology, and greater creativity in solving clinical problems," Califf said. "There’s no question when you look at the systems, the US has better access to cardiologists, better access to technology-not because as cardiologists you’re not smart enough to use it, you’re just not allowed to use it when you want to-and very rapid access to new technologies."

But then he admitted some more interesting nuggets

    "Yes, we cost more to the patient, and we have problems with prescription drugs, but in the category of respect for cardiovascular practitioners, there’s no question who gets more respect, and if you want to make more money, just move south"

His debating partner, Dr David Naylor responded that:

    Revascularization may provide a mortality advantage. From a broader population perspective, though, these differences are unlikely to change the fact that in overall survival after the age of 65, Canadians come out ahead of the US. "The US does of course come out ahead in what is spent," he added, roughly double that spent in Canada on care of the elderly.

In the last part of what was a pretty funny debate for a bunch of dry heart docs, Califf got rather serious and actually came over as a fan of the Canadian system but felt that it just needed more money:

    "I would submit that the US is going to have to become more like Canada in terms of its healthcare system, because there’s no other solution in sight, but I would also submit that if you don’t ratchet up your expenditures on healthcare with the demographic that you and we share, you’re going to be facing an even more explosive situation than you currently have."

However part of what he said in jest is true. It is logical for Canadian doctors who need no additional qualifications to work in the US to go south for another reason.  It pays better; much better!  Canadian physician incomes averaged about C$135,000, and even surgical specialists get only about C$180,000. In the US specialists in groups averaged somewhere between $150,000 and $350,000, primary care around $150,000–and don’t forget that Canadian dollars are worth 1/3 less than their American namesakes! In fact this chart of international physician incomes shows that virtually any doctor would be better off moving to the US. (Actually FYI Japanese doctors make more than Americans).  So when Medpundit says that Canadian doctors are coming here in droves, you can’t exactly blame them.  Only one little thing is a bit strange; they are not!

The brave folks from UBC led again by my old colleagues Morris Barer and Bob Evans, as reported in this issue brief called The myth of Canadian physician emigration, show that although roughly 500 doctors a year are leaving to the US, somewhere between 250 and 300 were coming back the other way, and that the deficit was more than made up of other doctors immigrating to Canada–mostly Brits who thought that Canadian pay scales were pretty good compared to what they got at home! Even at its greatest extent Canada was losing 1.4% gross of its physicians and more than making it up through returning Canadians and importing foreigners.  And even though Canada has fewer docs per head than the US (2.1 per 1,000 v 2.6) it has more than the UK or Japan (1.7 & 1.6) so these numbers are not significant either as a share of all doctors or proportionally to the population. It is worth pointing out that the other 99% of Canadian doctors didn’t believe that doubling their salary was enough to compensate for the associated unpleasantness of having to move to the US!

Conclusion: There are No Easy Answers

My primary objective in writing this piece is not to deride the good work done by those on all sides of this issue.  Instead it’s to show that while looking at international comparisons is valuable, it’s not OK to look on the surface and ignore the many complexities underneath that surface. Worse it’s totally dishonest to take "facts" out of context or tell blatant lies–but there’s no tax on lying.

Health systems everywhere are under financial strain–always have been and always will be. Canada certainly limits access to high technology and specialists by limiting investment in them upstream. The US does not, but citizens living in Canada are very unlikely to run into severe financial trouble because of their health–not so here.  Meanwhile, poorer Canadians have a roughly comparable experience with their medical system as do other Canadians.  Poor Americans certainly do not enjoy the benefits of their system as much as their richer compatriots. You might also have a sneaking suspicion that as their health system is more popular with Canadians than with their doctors (while the opposite is true in the US) perhaps the Canadian system is actually run in favor of the consumers rather than the producers of health care!

There are certainly cultural differences between Americans and Canadians, as Michael Moore pointed out in Bowling For Columbine. But there are also structural ones that are creations of policy. We are heading into a period of policy discussion again, and inevitably the Canadian system will come up in the conversation. It would be nice if that conversation was based somewhat in reality.

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28 replies »

  1. We do have a lot of health benefits as Canadians, and coming from a Canadian – I am very grateful for the basic health care that we receive. However, acquiring comprehensive health insurance is still a necessity in Canada. Luckily, there are some affordable plans that you can obtain.

  2. What’s interesting is that even though this blog post is some 7 years old, not a whole lot has changed, despite many different political changes within Canada and around the world. Wikipedia has a decent comparison between the health care between Canada and the US; it’ll be interesting to see how things change with Obama’s new proposed health care plans for Americans.

  3. Just read the comments given here , It is more or less the same situation in UK,We have seen a very huge increase in the purchase of private health care plans, I do not have any reason to believe this trend will decrease.

  4. I live and work in Japan. My employer pays part of my national health bill; I pay the rest from my paycheck. When I see a doctor or dentist for treatment, I pay 30% of the government-set price; taxpayers pay the other 70%. Right now, I have no complaints but I do buy worldwide coverage that runs about $3600 per annum.
    However, Japan’s system is crumbling. Demographics here are horrid, with over 20% of the population aged 65+ and Boomers set to retire and thus jack costs. There are cost control limits, such as one non-metal dental crown a year (after that, you pay 100%), and procedures not covered at all, including cosmetic surgery (certainly not when for vanity: no free boob jobs). Stroll about a major city and you might see people collecting money to see a sick person to the US for something that can’t be done here: either the expertise is lacking or it’s not covered.
    If you can’t pay that 30% of the medical tab, apparently it sucks to be you.
    One thing Japan lacks, fortunately, are the US-style trial lawyers who donate largely to the DNC (http://www.opensecrets.org/industries/indus.php?ind=K01). Tort reform might help lower medical costs by lowering malpractice insurance costs and reducing the self-protective need to order spurious tests.
    I have worked with a few Canadians (and other foreigners) and most, if they need serious medical care, check back home but often end up flying to Thailand or, less common, Singapore: cheaper, faster, comparable quality, English-speaking, and better weather.

  5. Many people have mentioned the German and French systems and have compared them to both the UK and Canadian systems. To me this seems problematic since the finances of both Germany and France aren’t exactly in good shape at the moment. From my experience in Europe, the health care system wasn’t very robust and spendy nor were there any features that were anywhere near advanced technologically. This leads me to believe that even while pinching pennies as the Germans and French are doing, the government still sucks at managing health care. Also I might suggest taking a simple economics course, it explains while not everyone can have the best…its called supply and demand.

  6. > I have on more than one occasion heard the doctors
    > in that institution and in private practice remark
    > that we really need a one payer system here.
    Sometimes I wonder if this is because it seems easier to manipulate one government payer than it is to negotiate with (say) half a dozen. I note also the management of the two kinds of payers face different incentives. Managers at For-Profit insurers compete for their salaries by delivering profits. Managers at government insurers compete for their salaries by delivering services to one group of people payed for by another.
    What astounds me is that expenditures in the government payer systems are as well-controlled as they are (even Medicare). I would’ve expected more pandering (“cute puppies and apple pie”) than there apparently is. For some reason, it seems like it is OK to berate and legislate against an evil Profit-Seeking HMO when it has cost-conscious care paths or standards of practice, but the government “HMO” is a different story. Probably cultural differences again. Any idea on this??

  7. I first want to say that there is no system that is perfect. In the States we pay far too much for treatment,thereby, as another correspondent said “rationing it”.
    While I cannot speak first-hand to the Canadian health care system, I can tell you that I have cousins in Ontario and they rave about it.
    As an immigrant to the USA from the UK, I can speak volumes on the subject of those two health care systems. I have been here for 40 years, and worked in a major medical institution on the East Coast for 30 of those years. I have on more than one occasion heard the doctors in that institution and in private practice remark that we really need a one payer system here.
    If you want to talk about the stepchild of the American health care system, think mental health. Even with good insurance it is difficult to get good mental health treatment, and even if you do it is more expensive and poorer than general health insurance. How often have we heard of someone with something like schizophrenia really losing it and murdering someone – even although they and their family members have tried to get the necessary treatment.
    On a more personal note, I have a brother who lives in England, and unfortunately he has recently been diagnosed with metastatic melanoma, a particularly deadly form of cancer. While there is no cure for it anywhere, he was immediately able to get treatment – no waits, no wondering how to pay for the treatment – and no fear of bankruptcy because of the health care available in Britain.
    I, myself, am reaching retirement age and I am toying with the idea of even while living in the US, buying British health insurance in order to be able to use it if, God forbid, I should have a very serious and chronic illness like cancer.
    It’s much cheaper to fly to London and get the treatment there than it is to try to get it here. Also, the treatment is just as good.

  8. On “The Eric Novack Show” yesterday, I interviewed Canadian Medical Association president Dr. Albert Schumacher about the Supreme Court decision. Among the many very interesting things he said about the ruling and Canadian healthcare were comments about the doctor shortage and “acceptable” waiting times.
    Currently 12% of Canadians do not have access to a primary care doctor. In Canada, that means it is essentially impossible to get a referral to a specialist. The population of Canada is approximately 32 million.
    Simple math tells me that, proprtionately, if the Canadian system were transplanted on the US- about 37 million Americans would not have access to the medical system through a primary physician. Sounds about like the number of uninsured…
    The CMA also has released guidelines on “acceptable” waiting times. This includes 9 months for a joint replacement…
    Hear the whole interview at http://www.ericnovack.com under “show archives”.

  9. I wish all Canadians could read your posting. There are many people in my country (Canada) who feel they can profit from inciting the public to be dissatisfied with an excellent (although not perfect) system.
    There are many business interests in Canada (who happen to own newpapers) who are very keen to see our public system go. A single payer system is simply not as profitable for business. But it does provide better care.
    I really appreciate your in-depth analysis of this issue. It is very salient today because the front pages of most Canadian newspapers this morning are declaring the end to medicare. There was a monumental ruling in a Quebec court yesterday that could be interepreted as calling the Canadian single payer system unconstitutional because it limits the rights of the top 10% of society to access the highest technology available.
    I have been a consultant to the medical device industry for several years and I have seen that the people who get the best care in the US society are the top 10% of the social economic class. Furthermore, the stocks of those 10% get a very healthy boost from the costly healthcare provided to the rest of society. Yet care in France, Germany, and Canada is typically better than the US for the majority of the population at a much lower cost to society.
    Most of those who think they would receive better care in the US would likely be disappointed to pay more for similar care. Yes, Canadian healthcare does need some improving. But right now there are only a few Canadians who would actually recieve better care in the US. Those happen to be the same people who are most vocal and most powerful in my country.

  10. The two-tier system will fast become a reality here in Canada. General perception here, at least in Ontario, is that we are being failed by the health system. While this isn’t necessarily the case, many services are no longer covered, and as mentioned wait times have increased.
    We are seeing a steady increase in the purchase of private health care plans, I do not have any reason to believe this trend will decrease.

  11. Canada’s health care system has generally taken the direction of more payments by its citizens for services, and in the long run insurance brokerages will get busier and busier as various govenment funded services are curtailed.

  12. It all makes interesting reading, although I and the rest of the 10 percent of the USA population having served in uniform during armed conflict might wonder if the USA can deliver universal healthcare of any type funding. The VA Healthcare System can often take up to one year to provide service to veterans in many parts of our nation. Any doubts of how relaxed the system has become can be confirmed by the American Legion and their recent survey of their membership and the ability of the Veteran’s Administration to provide even basic services as provided for under regulations. Before taking on the Canada’s abilities in the area of delivering healthcare, we might look at our own failure.

  13. People talk about Canadians as having a lower access to care or long wait times, implying that that’s because the state is rationing it in some presumably nasty way.
    But, most of Canada is rural.
    When I moved to a rural area in the US, I had to wait 3 months to get a ordinary yearly pediatric visit for my daughter. It had nothing to do with my ability to pay or not; it’s simply that this is the main pediatric practice for the area, and it draws from a very large geographic region – but apparently without enough population to support. another practice. When another family member was having asthma problems, a condition that usually gets you to the front of the line, I was given a one month lead time for the specialist or two months for the GP practice. (With repeated calls I lucked into a cancellation.)
    In the big city there are so many practicitioners, good practitioners, that you may not have to wait long if at all – regardless of your insurance situation. (Although many of my urban friends are reporting long lead times for first appointments also.) It may be that the immediate American appointment is as mythical as the Canadian waiting list.

  14. Exactly Richard,
    We should make it manditory that people buy health insurance exactly like auto insurance. We didn’t pass a law to require employers to purchase auto insurance on their employees and we should keep employer mandates out of health insurance too.
    Canada does not pay for health care in the United States. My private coverage is world wide coverage. I remember when a boulder hit a group of Germans on a bus in Colorado and the Germans wouldn’t pay for their citizens’ health care. Canada will never advertise that Canadians’ medical expenses will be paid in the USA, it would distroy their country in less than a year.

  15. Great myth busting treatment of the Canadian vs US systems. I would add two quick things….1) I agree with your emphasis on going below the surface. Case in point: I reviewed a study of cardiac catheterization procedures among Canadians and the authors found that, even in a universal health care system, those with higher socioeconomic levels had better access to cardiac catheterization that those with lower SES. 2) I encourage everyone, when talking about ‘rationing’ to admit that the U.S. Health Care System (even though there is no system) does ration. We just choose to ration by ability to pay or whether one has a job with insurance. I dont think its fair to let we Americans off the hook just because we dont have a centralized system of rationing like other countries.

  16. Good analysis of the nothing. I would like for people to look at some real facts. Most Americans spend more than $170/month for auto insurance, but still most won’t buy health insurance coverage (the healthy) because they feel it’s a waiste of $$$’s and it’s not mandatory. So let me get it straight….one can afford to buy auto insurance (mandatory in most states) but can’t afford health insurance??? I do understand many Americans are not eligible for ind. health coverage due to medical conditions, but most states offer comprehensive health insurance pools which will insure the uninsurable. Please put things in perspective….the problem with many Americans is that they can afford to spend $2,000 on Play Station 2 games at the same time refuse to pay a $2,400 annual health insurance coverage. Don’t beleive the hype…I’ve seen over 500 individuals (in the past 10 years) who have refused to pay health insurance premiums because they knew that if they were “uninsured”, the state would pay for their claims. Dr. Blobrain…get real.

  17. Good analysis. As one of the dreaded uninsured in America, I like to debate about better systems than our own. It’s a pain in the butt even when you’re insured, and if you’re not insured, you’re largely out of luck. I’ll use some of what you wrote, and hopefully we might convince enough people that we need something better. I just hope it happens before I get sick.

  18. Got here via Ezra, and I am glad I stopped by. Didn’t click on all the different links, but it is rather clear you are serious and open to discussion.
    I’ll pass it on to my friends who find this stuff important (as everyone should).

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