A few Differences to consider especially in cost saving with Universal Public Health Care.
The caricature of ‘socialized medicine’ is used by corporate interests to confuse Americans and maintain their bottom lines instead of patients’ health.
Universal health insurance is on the American policy agenda for the fifth time since World War II. In the 1960s, the U.S. chose public coverage for only the elderly and the very poor, while Canada opted for a universal program for hospitals and physicians’ services. As a policy analyst, I know there are lessons to be learned from studying the effect of different approaches in similar jurisdictions. But, as a Canadian with lots of American friends and relatives, I am saddened that Americans seem incapable of learning them.
Our countries are joined at the hip. We peacefully share a continent, a British heritage of representative government and now ownership of GM. And, until 50 years ago, we had similar health systems, healthcare costs and vital statistics.
The U.S.’ and Canada’s different health insurance decisions make up the world’s largest health policy experiment. And the results?
On coverage, all Canadians have insurance for hospital and physician services. There are no deductibles or co-pays. Most provinces also provide coverage for programs for home care, long-term care, pharmaceuticals and durable medical equipment, although there are co-pays.
On the U.S. side, 46 million people have no insurance, millions are underinsured and healthcare bills bankrupt more than 1 million Americans every year.
Lesson No. 1: A single-payer system would eliminate most U.S. coverage problems.
On costs, Canada spends 10% of its economy on healthcare; the U.S. spends 16%. The extra 6% of GDP amounts to more than $800 billion per year. The spending gap between the two nations is almost entirely because of higher overhead. Canadians don’t need thousands of actuaries to set premiums or thousands of lawyers to deny care. Even the U.S. Medicare program has 80% to 90% lower administrative costs than private Medicare Advantage policies. And providers and suppliers can’t charge as much when they have to deal with a single payer.
Lessons No. 2 and 3: Single-payer systems reduce duplicative administrative costs and can negotiate lower prices.
Because most of the difference in spending is for non-patient care, Canadians actually get more of most services. We see the doctor more often and take more drugs. We even have more lung transplant surgery. We do get less heart surgery, but not so much less that we are any more likely to die of heart attacks. And we now live nearly three years longer, and our infant mortality is 20% lower.
Lesson No. 4: Single-payer plans can deliver the goods because their funding goes to services, not overhead.
The Canadian system does have its problems, and these also provide important lessons. Notwithstanding a few well-publicized and misleading cases, Canadians needing urgent care get immediate treatment. But we do wait too long for much elective care, including appointments with family doctors and specialists and selected surgical procedures. We also do a poor job managing chronic disease.
However, according to the New York-based Commonwealth Fund, both the American and the Canadian systems fare badly in these areas. In fact, an April U.S. Government Accountability Office report noted that U.S. emergency room wait times have increased, and patients who should be seen immediately are now waiting an average of 28 minutes. The GAO has also raised concerns about two- to four-month waiting times for mammograms.
On closer examination, most of these problems have little to do with public insurance or even overall resources. Despite the delays, the GAO said there is enough mammogram capacity.
These problems are largely caused by our shared politico-cultural barriers to quality of care. In 19th century North America, doctors waged a campaign against quacks and snake-oil salesmen and attained a legislative monopoly on medical practice. In return, they promised to set and enforce standards of practice. By and large, it didn’t happen. And perverse incentives like fee-for-service make things even worse.
Using techniques like those championed by the Boston-based Institute for Healthcare Improvement, providers can eliminate most delays. In Hamilton, Ontario, 17 psychiatrists have linked up with 100 family doctors and 80 social workers to offer some of the world’s best access to mental health services. And in Toronto, simple process improvements mean you can now get your hip assessed in one week and get a new one, if you need it, within a month.
Lesson No. 5: Canadian healthcare delivery problems have nothing to do with our single-payer system and can be fixed by re-engineering for quality.
U.S. health policy would be miles ahead if policymakers could learn these lessons. But they seem less interested in Canada’s, or any other nation’s, experience than ever. Why?
American democracy runs on money. Pharmaceutical and insurance companies have the fuel. Analysts see hundreds of billions of premiums wasted on overhead that could fund care for the uninsured. But industry executives and shareholders see bonuses and dividends.
Compounding the confusion is traditional American ignorance of what happens north of the border, which makes it easy to mislead people. Boilerplate anti-government rhetoric does the same. The U.S. media, legislators and even presidents have claimed that our “socialized” system doesn’t let us choose our own doctors. In fact, Canadians have free choice of physicians. It’s Americans these days who are restricted to “in-plan” doctors.
Unfortunately, many Americans won’t get to hear the straight goods because vested interests are promoting a caricature of the Canadian experience.
Michael M. Rachlis is a physician, health policy analyst and author in Toronto.
What’s so great about private health insurance?
The bloody battle in Congress over a ‘public option’ ignores the insurers’ role in creating the nation’s healthcare crisis and their efforts to throttle reform.
Throughout the heroic struggle in Congress to provide a “public option” in health insurance, one question never seems to get answered: Why are we so intent on protecting the private option? The “public option,” as followers of the debate know, is a government-sponsored health plan that would be available as an alternative to, and in competition with, the for-profit health insurance industry, otherwise known as the private option. On Friday, the House Committee on Energy and Commerce narrowly passed a reform bill incorporating a public option resembling Medicare. It was a bloody fight among members of Congress, some of whom believe that the public option will give the government unwarranted power over healthcare, and all of whom enjoy government-provided healthcare that’s a lot better than what most of us get. But the battle is just beginning. After the committee vote, House Speaker Nancy Pelosi warned that the health insurance industry will conduct a “shock and awe” campaign to kill the public option when Congress returns from vacation in September and starts debating the measure. We can expect to be overwhelmed with an industry ad campaign worth millions of dollars (remember Harry and Louise?) exhorting us to write our lawmakers to preserve the American way of healthcare. So it’s proper to remind ourselves what that American way entails. For if the insurers have proved anything over the last 15 years as the health crisis has gathered speed like an avalanche roaring downhill, it’s that they’re part of the problem, not the solution. The firms take billions of dollars out of the U.S. healthcare wallet as profits, while imposing enormous administrative costs on doctors, hospitals, employers and patients. They’ve introduced complexity into the system at every level. Your doctor has to fight them to get approval for the treatment he or she thinks is best for you. Your hospital has to fight them for approval for every day you’re laid up. Then they have to fight them to get their bills paid, and you do too. One Wendell Potter reminded a Senate committee in June that health insurance executives had assured Congress in 1993 that they would work to secure universal medical coverage and end denials of coverage to people with pre-existing conditions. Then they moved heaven and earth to kill reform. They’ve made the same promises now, Potter observed. But they’re in an even better position to throttle reform. Mergers and acquisitions have turned the industry into a cartel of huge corporations. “The industry is bigger, richer and stronger, and it has a much tighter grip on our healthcare system,” he said. The last thing they want is a government program set up as their competition. Potter knows the insurers’ ways because he was a top executive in the industry for 20 years. But the hard numbers bear him out. The two largest insurers, WellPoint and UnitedHealth Group, each acquired 11 other insurers between 2000 and 2007. They now control a total of 67 million “covered lives” (that’s customers in health insurance-speak). This consolidation has produced functional monopolies in communities across America. The American Medical Assn. (itself no great fan of reform) found in a 2007 survey that in 76% of the country, defined as its major metropolitan statistical areas, one insurer had a share of 50% or more of the conventional insurance market. This phenomenon gives the companies enormous power to drive up premiums and maximize profits. Why do we tolerate this? The industry loves to promote surveys indicating that most Americans are “satisfied” with their current health insurance — 37% are “very satisfied” and 17% “extremely satisfied,” according to one such study. Yet these figures are misleading. Most people are satisfied with their current insurance because most people never have a complex encounter with the health insurance bureaucracy. Medical care generally follows the so-called 80-20 statistical pattern — 20% of patients consume 80% of care. If your typical encounter is an annual checkup or treatment of the kids’ sniffles, or even a serious but routine condition such as a heart attack, your experience is probably satisfactory. But it’s on the margins where the challenges exist. Anyone whose condition is even slightly out of the ordinary knows the sinking feeling of entering health insurance hell — pre-authorizations, denials, appeals, and days, weeks, even months wasted waiting for resolution. And that’s among people with affordable employer-paid insurance, an ever-shrinking cohort. The percentage of small and medium-sized businesses offering health coverage to employees shriveled to 38% from 67% between 1995 and 2008, according to the National Small Business Assn. Without reform, the number will continue to plummet. Meanwhile, people employed by big companies that offer a health plan are within a layoff notice of losing coverage for themselves or their families, joining America’s 46 million uninsured. Their only alternative right now is the individual market, where insurers scrutinize applicants’ medical histories, looking for reasons to turn them down or charge them exorbitant premiums. Have hay fever, asthma, a cholesterol pill prescription? Are you a woman of child-bearing age? You’re virtually uninsurable at an affordable cost. Even if you’re accepted, your carrier reserves the right to cancel your policy retroactively if it finds that you left even a tiny condition from years back off your application. The public option may be your lifeline — if it’s enacted. Signs of the industry’s mobilization against the public option are everywhere. I don’t claim clairvoyance for having predicted this development back in March; given the industry’s record on reform, a child could have done so. You’ve heard of the Blue Dog Democrats, those mostly rural conservatives who blocked a summertime vote on reform legislation on Capitol Hill? According to the Center for Public Integrity, the biggest backer of the Blue Dogs’ political action committee is the healthcare industry, which is on the path to pumping a total of $1.2 million into the PAC’s maw in the current 2009-10 election cycle. Then there’s the advocacy group called the Campaign for an American Solution, which describes itself as “a grass-roots effort . . . to build support for workable healthcare reform.” The organization owns up to being an “initiative” of America’s Health Insurance Plans, or AHIP, the industry’s chief lobbying arm. Unless I’ve missed a radical change in lawn and garden horticulture, you can’t get much further from the grass roots than to be a creation of the industry with the biggest stake in the debate. Despite all this, America’s health insurance plans, which helped create our dysfunctional world, are deferred to as though they’re a disinterested party. AHIP subtitled one of its policy papers “A Vision for Reform.” But are the insurers now, and have they ever been, anything other than a roadblock?