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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.

POLICY: State budget crunches are real

Just in case you thought that state budget deficits caused by the ruinous Bush deficit/ending of the Clinton bubble (delete where applicable to suit your political taste) were somewhat academic, read this report on Colorado’s decision to remove legal immigrants from Medicaid eligibility.

I strive to be neutral in this blog, but on this issue I’m very biased. I’m a US citizen now, but I was a legal immigrant for many years.  The only difference between being a green card holder and a citizen is that you can’t vote or do jury duty. Importantly you still pay the same taxes as every one else and presumably these Medicaid patients did too. It also looks that some workaround will be discovered to pay for their care, maybe. However, aside from the politics, the fact that the state is desperate enough to consider putting some 150 elderly nursing home residents out on the street, shows that this crisis in funding is real.

POLICY: Medicare competition as a political football.

The New York Times points out a couple of things about the Medicare bill negotiations in this article, Competition Causes Widest Split Over Medicare. These issues won’t be strangers to those reading TheJeanneScottLetter, whether or not you were sent there by me.

Here’s the short-hand. The House bill introduces the notion that Medicare needs to compete with private plans, rather then allowing them as an option under Medicare+Choice as now.  In order to give this some teeth, it looks like premium cost-sharing, based on income, is emerging from the current Senate-House negotiations. The Democrats led by Ted Kennedy see the long term outcome of this being Medicare as welfare, with only some people getting a flat payment (defined contribution) to spend as a voucher amongst competing plans. Unstated is the Democrats belief that the private plans would skim the healthier and wealthier from the public plan, which would be left with those who couldn’t "trade up" to join the private plans,  and that traditional Medicare would be forced to cut services, and would eventually go broke.

That’s as maybe.  When Medicare Risk plans were growing in the early 90s they were able to make money getting 95% of the average cost of a recipient in the local area for each member they signed up, and usually they got people to sign up by offering them free insurance for drugs with no extra premiums. Several reports at the time suggested that plans were signing up healthier patients than average, and thus were skimming (duh!).  However, at some point even those patients got sick and more importantly payments were not put up in line with medical costs. The result was that benefits were cut within the Medicare Risk plans, and then many private plans pulled out of Medicare risk altogether. The percentage of Medicare enrollees in managed care plans went from 10% in 1995 to 18% 2000 but fell to 13% in 2003 (all January numbers, for more see the CMS site here).

What this tells me is that the government can pass regulations that can change health plan behavior in terms of its recruitment and profitability. So if a benevolent HIPAA administrator was sent down from Mars to run a neutral system in which there were private and public plans competing and incentives were designed to be even, it is possible that a mixed system could work. It might even improve the efficiency and quality of care delivery.

But this is politics and that’s not going to happen. Note that the House bill which includes the privatization thrust only passed by one vote, while the Senate bill had broader approval among Democrats. Bush will soon have to make a call as to whether it’s more important to shore up his support amongst conservative Republicans in the House, or whether it’s worth using his eroding political clout to have them cave on that, in order to be able to campaign as the President who passed Medicare drug coverage. If he does and if Medicare Reform passes including real competition between Medicare and private plans, watch out for a large battle in the years to come as this concept moves into reality. But realistically that’s looking less and less likely.

Up date: Harris Interactive’s latest poll shows that there’s a slight uptick in support for the Democrats on the health care issue with a plurality favoring the Dems 35% to 20%, although they don’t think it’s big enough for the Dems to be happy. Interestingly, among the over-65s who matter most in health care politics, it’s ony 36%-30% in favor of the Dems.

PHARMA: Is it Nature or Nurture?

Remember the movie Trading Places when two rich old men put Dan Akroyd into the gutter and take Eddie Murphy out of it to figure out whether it’s nature or nurture that affects people’s outcomes?  Well there’s an equivalent going on in the Pharma industry right now. In this article, Fred Hassan’s Clean House, Forbes reports that almost all Schering-Plough’s management team have now followed him over from Pharmacia.  You may recall that Hassan went to Schering when he had a bit of free time on his hands, having very successfully sold Pharmacia to Pfizer for $58 billion in 2001. But you might also recall that at Pharmacia, Hassan had good drugs like the blockbuster Celebrex, Bextra , and some strong  therapeutic franchise’s elsewhere.

Now the whole team is over at Schering they’ll see whether they can make a success of going from the penthouse to the gutter (relatively speaking of course!).  Schering isn’t quite out of revenue or products but it will be nowhere near as easy a management job for this team as they had at Pharmacia. It reminds me a little of the Dilbert cartoon when the pointy haired boss announces to Dilbert and colleagues that "We always say that people are our most valuable asset, but I just did an audit and found that money is our most valuable asset–people came in 9th." Now Hassan and his team can prove that it is people not blockbuster product that can move the stock price.

Oh, and in Trading Places Eddie Murphy shone in the penthouse and Dan Akroyd (initially) fell to pieces in the gutter, showing that nurture or environment or, in pharma terms, product was the determining factor!

INDUSTRY: New HealthSouth management blames Scrushy

I know that you’re tired of hearing about it and I promise that this will be the last article I ever write about Healthsouth–but I couldn’t let go the little fact that, surprise, surprise, the new management that’s been in charge of Healthsouth–since the scandal broke earlier this year and they kicked out newly-indicted Richard Scrushy–says that it’s all his fault.

(Lucky this isn’t a video-blog so you didn’t notice me typing this with one hand, as the other had my fingers crossed behind my back).

PHARMA: A little more info on Crestor

There’s a little more info about the adverse events with Crestor, in a report called What’s the Matter with Crestor? from Friedman, Billings, Ramsey & Co Research. (I couldn’t find a way to get the report without opening a brokerage account!).

The research suggests so far that Crestor is not doing as well in the marketplace as was expected, and is being outpaced by Schering & Merck’s non-statin, LDL-lowering drug Zetia, which can be taken in addition to statins or by itself, and is useful for at least the 5% of population that cannot tolerate statins. The report says

    Data indicate that thus far, Crestor’s launch has been significantly slower than that of Zetia, a non-statin cholesterol-lowering drug, comparing total script volumes at similar times after launch. This is underscored by the fact that two recent comparator weeks for Zetia include the Christmas and New Years holidays, weeks that are typically slow for prescription volumes, and surprisingly, Zetia is still exceeding Crestor on an absolute basis. Crestor also lags Zetia in NRx market share, according to prescription audit data, holding 2.22% NRx share compared to Zetia’s 2.65% at similar periods in the launch trajectory, a better comparison than total prescriptions in our view, because it is less dependent on the absolute size of the market.

Translation for non-pharma folks is that Crestor hasn’t taken up as well as it might have done. Meanwhile the report also goes onto to confirm some of the issues around safety. You’ll recall that Public Citizen, and The Lancet have been bringing this issue to the forefront.

    According to the Medicines and Healthcare Products Regulatory Agency in the U.K., there have been 41 reports reflecting 45 muscular reactions associated with Crestor use. Of those reports, 35 were associated with the 10mg dose of the product, and notably, 3 of the reactions involved moderately increased levels of Creatine Phosphokinase (219-436 IU/L), according to data from the agency. Based on our research, normal Creatine Phosphokinase levels are in the 30-170 IU/L range and elevations associated with severe rhabdomyolysis are typically in the 35,000 IU/L range and up. The U.K. agency cautions that suspected adverse reactions are not necessarily caused by the drug and may relate to other factors such as underlying illnesses or other medicines; however, we believe that the early reports of muscle-related adverse events at the most common starting dose are notable.

I repeat that I am not a scientist or physician and have little understanding of the seriousness of these findings.  However, 35 of 45 muscle problems were reported on the 10mg dose– 1/4 of the dose that concerned The Lancet, and there were three reports of increased Creatine Phosphokinase which is a precursor to rhabdomyolysis. The question is whether the medical community views this as minor or whether they perceive that these very initial results are indicators of more trouble to come.

QUALITY QUICKIE: Are hospitals screwing over MD whistleblowers?

Via DB’s Medical Rants, I found this series in the Pittsburgh Post-Gazette on how hospitals are using a wrinkle in an obscure 1986 Act to ruin–literally, professionally and financially– doctors who blow the whistle on poor quality care.  There are many short readable stories in this series, which is in day number 4.

We know from IOM reports and other sources that there are many mistakes made inside hospitals, and we know that many hospitals are desperate to improve their bottom lines, and avoid scandal, and would probably rather not hear about those errors.  So in my view, as Schwarzenneger said, where there is smoke there is usually fire. Go read and be very scared that this type of thing is going on, and then wonder if we really are serious about care quality.

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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