POLICY: A rural California MD comments on the CHCF studies

Leonard Soloniuk, MD, wrote in to THCB to comment on my post on Frday linking the care for Medicaid and uninsured patients in California with the Canadian experience. A post in which I was a little shrill about certain American and Canadian critics of the Canadian system. He has an interesting perspective on the type of problems the CHCF reports were describing.

    I’m always surprised by the continued criticism that the Canadian health care system gets for lack of access when I see equally serious problems in the US.

    My perspective: I am a specialist in a rural, mostly indigent county in Far Northern California. Medi-Cal patients can get primary care easily enough (wait list for a new patient is about 2 months) because the county clinic is heavily subsidized by the Feds and the state (the clinic gets about $75 per patient visit, while I get about $18 per Medi-Cal patient visit). Because of the disconnect between cognitive and procedural reimbursement (a whole different subject), there is usually not much of a problem getting surgery for Medi-Cal patients. Medi-Cal actually pays better than private insurance for many surgeries. However, there are still significant waits for certain specialities: 12 months for Urology, 6-12 months for Neurosurgery, for example. For non-procedural specialities, there are significant delays, such as 12 months for Rheumatology.

    These waits sound just as bad as the Canadian system, but I just don’t see them mentioned in articles comparing the two systems.

    Of course, the uninsured can face significant barriers to care. The barriers are so discouraging that it is my office policy not to see uninsured patients (I policy that I violate only once a week or so). I don’t see them because I can’t provide good care for them. I can’t order lab work, xrays, scans. Interestingly, the lowest barrier for the uninsured patient is for medications. Between samples and pharmaceutical programs for indigents, I can almost always get meds for the patients.

    Thinking about this issue some more, I think that the speciality with the worst problems for access to care is psychiatry. Access to mental health care is difficult even for insured patients, because of higher co-pays, etc. For the indigent, the resources are awful. “It really sucks to be mentally ill and poor in America.”

    I’ve never seen any comparison about access to mental health care in Canada or England. Any comments?

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