Rational Arguments

Everyone knows drugs cost too much in the United States.  Many people also know tat in other countries – like Canada – those same drugs cost much less.

Over the last week, there’s been a surprising amount of debate in the Senate over an amendment to allow us to import cheaper drugs from Canada.  Although many oppose it, there are a fair number of Republicans who don’t.

One of the reasons drugs cost so much in the US is that we can’t collectively bargain to reduce prices.  In Canada, the country can negotiate as one huge purchaser, and can therefore get a good deal.  In the US, on the other hand, Medicare is expressly forbidden by law from doing so.  That was part of the deal when Medicare Part D was passed.  So no bargaining.

That was a pretty bad deal as agreements go.  We committed massive federal funds to purchase drugs from pharmaceutical companies and then also barred the government from trying to get a good rate.  Not only has that significantly increased the deficit, but it seems bizarre from an economic standpoint.  Are there other industries where it’s illegal for the government to try and negotiate for a good deal?

It’s crazy, though, to support those same bans and then support importing from countries with no such bans.  Huh?  Either you like collective bargaining or you don’t.  It seems very inefficient not to bargain with our very large Medicare system and then pay Canada overhead to allow them to do lesser bargaining for us.  Why not just let our government get better prices?  Why go to other countries instead?  Why is that logically consistent?

I’m not kidding.  Someone please explain it to me!

I was on Stand Up! with Pete Dominick this afternoon, and a caller asked a question I get asked all the time.  Basically, he was citing the “fact” that doctors would quit being doctors if there was major health care reform because they won’t make as much money.  Or something.  But it all gets down to the same thing – doctors hate single payer, right?

I can’t even count the ways this is untrue.

Let’s start with my own research showing that doctors in the United States would support national health insurance:

Methods: We randomly sampled 5000 physicians from the American Medical Association Masterfile. We sent each physician a survey asking 2 questions: 1) In principle, do you support or oppose government legislation to establish national health insurance? and 2) do you support achieving universal coverage through more incre- mental reform? Question 1 was identical to the one we used in our 2002 study (3). Respondents answered using a 5-point Likert scale. We also gathered data on physician membership organizations and demographic, personal, and practice characteristics.

This was the largest mail survey of physicians ever done on health care reform.  It was a follow up study of work we had done five years earlier.  And what did we find?

Look at that.  59% of all physicians supported government legislation to establish national health insurance.  A majority of every specialty except three supported national health insurance.  Every specialty we measured in both 2002 and 2007 increased support for national health insurance (except pediatric subspecialists which stayed the same at 71%).  Almost twice as many physicians support national health insurance as oppose it.

That’s 59% for national health insurance.  Remember that when people start saying physicians oppose reform.

Another popular form of this argument is that “doctors are flocking to the US from Canada”.  You can’t imagine how many people I meet who claim to know such a doctor.

Well, it’s true that years ago there was a net influx of docs into the US from Canada.  No longer:

What you are looking at is data from the Canadian Institute for Health Information.  The important line is the yellow one, which is the net loss of docs to Canada.  Even in the worst year, fewer than 700 more docs moved to the US than moved to Canada.  But, since 2003, there has been a net movement of docs into Canada from the US.

It’s not that docs are fed up with Canada and moving to the US.  If anything, it’s the opposite!

When people want to demonize single payer systems, they always wind up going after rationing, and more often than you’d think with hip replacements.  Here’s Rep. Todd Akin (R) on the House floor yesterday:

“I just hit 62, and I was just reading that in Canada [if] I got a bad hip I wouldn’t be able to get that hip replacement that [Rep. Dan Lungren] got, because I’m too old! I’m an old geezer now and it’s not worth a government bureaucrat to pay me to get my hip fixed.”

Sigh.  This has been debunked so often, it’s tiring.  But here:

“At least 63 percent of hip replacements performed in Canada last year…were on patients age 65 or older.” In 2006-2007, an additional 1,577 hip replacement surgeries were performed in Canada on patients over 85.

It’s not true.  They don’t deny hip replacements to the elderly.  But there’s more.

Do you know who gets most of the hip replacements in the United States?  The elderly.

Do you know who pays for care for the elderly in the United States?  Medicare.

Do you know what Medicare is?  A single-payer system.

A reader responds:

In response to directing some to your article on USA/CAN angle, I was referred to this article from late August:

Canadians visit U.S. to get care

Have you seen this?

Here’s my take.  What you are seeing is a system that spends far less than we do deciding it’s more cost-effective to send some people with specific needs (like bariatric surgery) to the US to get them met.  In other words, it’s cheaper to use scanners in the United States than buy their own. Seems smart to me.

Notice that this is specifically to reduce wait times.  Are we now demonizing them for that? Sounds like they are taking advantage of the fact that we have so much invested in technology that it’s sitting around waiting to be used.  If they choose to pay us for that, how is that bad?

Again, this is the SYSTEM in Canada compensating, not people forced to go to the US because of rationing.  I think we would applaud the ingenuity of this single-payer system to solve problems. Not to mention I fail to see how this points to the success of the insurance system in the United States.

Finally, this is a piece in an online business journal, not reproducible scientific research.  It’s just above anecdote; you know how I feel about anecdotes.

I encourage everyone to read the article.  Make your own judgement.

A well used meme in the health care debate is that Canadians – frustrated by wait times and rationing – come to the United States for care.  These are almost always anecdotal stories and, well, go to the about the blog page to see what I think of anecdotes.

We should rely on evidence and research; it does exist.  The most comprehensive work on this topic was published in the peer-reviewed journal Health Affairs.  This study examined Canadians crossing the border for care in a number of ways:

1) First, they surveyed United States border facilities in Michigan, New York, and Washington.  It makes sense that Canadians crossing the border for care would favor sites close by, right?  It turns out that about 80% of such facilities saw fewer than one Canadian per month.  About 40% saw none in the prior year.  And when looking at the reasons for visits, more than 80% were emergencies or urgent visits (ie tourists who had to go to the ER).  Only about 19% of those already few visits were for elective purposes.

2) Next, they surveyed “America’s Best Hospitals”, because if Canadians were going to travel for care, they would be more likely to go to the most well-known and highest quality facilities, right?  Only one of the surveyed hospitals saw more than 60 Canadians in one year.  And, again, that included both emergencies and elective care.

3) Finally, they examined data from the 18,000 Canadians who participated in the National Population Health Survey.  In the previous year, only 90 of those 18,000 Canadians had received care in the United States; only 20 of them had done so electively.

So there you go.  Three different methodologies, all with a solid rationale behind them, all showing that the meme is a myth.  Maybe that’s why the paper was titled, “Phantoms in the Snow.”

Whenever I speak about the quality of the US health care system, I talk about a handful of indicators that organizations use to compare different systems.  Inevitably, someone chooses one of them, and then starts to scream that because THAT one indicator is flawed, everything I said is a lie.  The biggest one people like to pick apart is infant mortality.

My response is always the same:

To be honest, there is some truth in what you are saying.  Bottom line, [insert measure here] is flawed.  All measures are.  That’s why you will never hear anyone who is serious about this issue use [selected measure] as the only measure to promote single payer.  It is one of many.  As I usually say, “it doesn’t matter which metric you pick, life expectancy, infant mortality, maternal mortality, levels of vaccination, continuity of care, access, cost, or most importantly, preventable years of life lost – the US is middling at best and often worst when compared to comparable nations.”

That said, you would hope that we wouldn’t place LAST in [selected measure] when compared to other countries, and with all the spending we do on our health care system, it certainly isn’t getting us the quality you expect.

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