Rational Arguments

A reader writes:

We Canadians like to brag about our health care system but we often forget that while we look good compared to the US, compared to the rest of the world we’re not quite so good.  The chart on your June 23 post seems to confirm that, with Canada placing last (7th) in several categories including timeliness of care, effective care, and quality care (overall.)  Even in most of the other categories we place well down the list with lots of 5′s and 6′s, including a 6th place standing for Overall Ranking.

Yet on Long, Healthy, Productive lives (which I would argue is truly the best metric) we place 2nd!  Given our dismal performance in so many of the other categories, this seems particularly out of place.  Can you shed some light on this apparent contradiction?

(Don’t get me wrong, I’m quite happy with my health care.  I’m just very confused by the chart.)

Lots of good stuff in here.  The simplest explanation is that “long, healthy, productive lives” are due to much more than just the health care system.  I can think of any number of public (or private) things that could improve this metric that have nothing to do with the health care system.

This illustrates a larger point.  We shouldn’t focus on any one metric to measure anything.  It’s very easy to cherry pick one statistic and then claim victory.  For instance, I bet we do more pancreas transplants in the United States than anywhere else in the world.  If we use that as the only metric, then we can hold a parade today; we’re number one!  Similarly, if you use only “long, healthy, productive lives”, then Canada is number 2.  Go celebrate.

This is why whenever you hear me talk about the quality of the US health care system, I rattle of a host of different metrics.  You can’t pick any one.  They are all flawed in some way.  But, when together they paint a pretty consistent picture (as they do in the chart I posted), you have to start believing that picture is true.  To quote myself about the US:

Last in efficiency.  Last in equity.  Last in long, healthy, productive lives.  Last overall.

Next to last in quality care.  Tied for last in access.

So I repeat.  Tell me where the good news is in there.

Here’s another point that’s often overlooked.  It’s not by chance that people who want to demonize health care reform in the US always pick on Canada.  It’s because you’re not the best in the world, either.  You’re #6 to our #7 in this case.  If they want to look for someone to pick on, they are certainly not going to turn to #1 or #2.

This isn’t to say your system isn’t better than ours in many respects.  It’s just got room for improvement, too.

While the health care debate has abated somewhat in the US, it is still ongoing in Canada.  On Monday, there was a debate, on whether people “would rather get sick in the U.S. than in Canada”.  One of the participants was Howard Dean.  The Globe and Mail interviewed him before the debate:

People tend to forget that you already have some socialized medicine in the U.S., as well as a large single-payer system.

Medicare is not socialized, not in the U.S. and not in Canada. It’s a single-payer system. Despite what is often said, your system is not socialized, it’s a single-payer insurance system. The Veterans Health Administration, however, which has 25 million people in it, is a truly socialized system – it’s government-owned and government-operated and it’s worked very well. In fact, the VHA is the No. 1 rated system in the country, according to patients.

Health-care reform dominated the headlines for a long time. Was it successful?

We didn’t pass reform. All we did pass was putting more money into what we already have. It’s successful in a sense that 1) we got a major bill passed, which is something for a new administration; 2) we created a system that’s going to force reform because of the financial realities; 3) a great many more people are going to have coverage. But this system is still not nearly as effective and efficient as the Canadian system.

You’re a physician. There is an assumption physicians don’t like a universal system because, with less competition, they come out losers.

I know a lot of American physicians who would much rather practise under a Canadian model. There is less malpractice, more actual health care, and a lot less bureaucracy like insurance forms to fill out. I think it depends on why you went into medicine. If you want to make a lot of money, the Canadian system is not for you; if you really like to take care of patients, the Canadian system is well suited.

What’s the single most important lesson that Americans can take from the Canadian system?

It covers everybody with a relative lack of bureaucracy. I know Canadians think there is bureaucracy, but you haven’t seen anything until you work in a system with several hundred insurance companies that all do something different. American hospitals have a whole floor occupied by a billing office. You don’t have that in Canada.

Conversely, what’s the most important lesson Canadians can take from the U.S. health-care system?

I’m afraid I’m not sure there is one. There is more cutting-edge innovative technology, but the cost of that is to pay 70 per cent more than Canadians do for health insurance. Canadians will have to decide if that’s a lesson they want to learn.

Bottom line, which system is better for the patient?

I’ve spent a lot of time in both countries and there is no doubt that you’re better off getting sick in Canada.

I don’t have much to add to the content Dr. Dean offers here.  I agree with it.

But why is it that politicians only seem to be able to speak honestly and clearly when they aren’t talking to Americans?  Where was this guy during the health care reform debate?  Instead we got confusing and confounding stuff like this and this and this and this, ending with this.

Every once in a while, someone has to wheel out the usual story on how Canada’s health care system is about to collapse.  Today, it was Reuter’s turn:

Pressured by an aging population and the need to rein in budget deficits, Canada’s provinces are taking tough measures to curb healthcare costs, a trend that could erode the principles of the popular state-funded system.

Before I even get into this, can we acknowledge that rising health care costs in not a Canadian problem, but a worldwide problem?  Please remember as we go through the rest of it that – today – we spend about twice per person what Canada does on health care.  If they are complaining that it costs too much, what are we doing?  And while they spend about 10% of GDP on health care, we spend 16%.  So anyone who points to their model as “unable to contain costs” should just shut up.

Anyway, here is my favorite line:

In some ways the Canadian debate is the mirror image of discussions going on in the United States.

Canada, fretting over budget strains, wants to prune its system, while the United States, worrying about an army of uninsured, aims to create a state-backed safety net.

Huh?  We already have a safety net. It’s called Medicaid.  It’s not as good as I like but it exists.  This reporter, however, seems to think that the ACA is about the safety net.  It’s not.  It’s mainly a huge plan to give taxpayer money to people to buy private insurance.  It’s an expansion of the private system, albeit with government money.  It’s not some new government plan.

Moreover, Canada wants to contain rising costs.  Like we should.  But as they take steps to be fiscally prudent, we deride them as failures.  Here’s a United States Senator:

What will happen in the U.S.? | Reuters: Soaring costs force Canada to reassess health model

Soaring health costs?  As opposed to here?  Am I losing my mind?

They quote four people in the article.  One is the Ontario Finance minister.  He says:

“Our objective is to preserve the quality healthcare system we have and indeed to enhance it. But there are difficult decisions ahead and we will continue to make them”

Seems reasonable enough.  I don’t disagree.  You would think, that if this was an article describing the upcoming demise of the single payer system, that there would be other politicians calling for, say, the demise of the single payer system.  But no.  Instead, we get the following three players:

1) A senior economist at Toronto-Dominion Bank.  You read that right.

2) A professor at University of Toronto’s Rotman School of Business.

3) A senior economist at Scotia Capital.  What is Scotia Capital?  This is Scotia Capital:

Scotia Capital is the marketing name covering the Scotiabank Group’s integrated global corporate and investment banking and capital markets functions. Scotia Capital’s global operations are divided into two primary business units:

Global Corporate and Investment Banking

Global Capital Markets

In Canada, Scotia Capital offers a full range of corporate and investment banking and capital markets products and services.

Really?  This is who they went to for health policy expertise?  Can you possibly predict what she will advise?

Scotia Capital’s Webb said one cost-saving idea may be to make patients aware of how much it costs each time they visit a healthcare professional. “(The public) will use the services more wisely if they know how much it’s costing,” she said.

“If it’s absolutely free with no information on the cost and the information of an alternative that would be have been more practical, then how can we expect the public to wisely use the service?”

Ah….  the moral hazard.  Like music to my ears.

No health policy experts.  No politicians advocating for change.  A bank economist, a business professor, and an economist for Scotia Capital.  The article never mentions that the single payer system in Canada is wildly popular.  The article never mentions that no serious politician is running on a platform of repealing it.

But most importantly, the article never mentions that the Canadian health care system is not like ours in any way.  No matter what headline you read, the ACA is not a single payer system.  The ACA changed very little structurally.

Our system is still mostly private.  Ours costs way more.  Ours covers far fewer people.  And ours has similar, if not worse, outcomes.

Our system is nothing like Canada’s.  We should be so lucky.

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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