Thursday, September 20, 2012

Behind the lines of socialized medicine

Obamacare can be described as a lot of different things, but it surely is not socialized medicine.   No self-respecting socialist would favor having the government write checks for 16 million people to buy coverage from private (and often for-profit) private health insurance companies.  Plus, the Affordable Care Act maintains the employer-based coverage system from which the vast majority of Americans will continue to get coverage.  Heck, it doesn’t even have the public option favored by liberals! 

I write this blog today from a country that has the real thing: Canada!  ACP’s Board of Governors is meeting this week in beautiful Vancouver, British Columbia.   Coincidentally, one of the policy resolutions being debated this morning by the governors is a call for ACP to support a single payer system, like Canada’s.  (Resolutions can be introduced by any ACP chapter, so the fact that this resolution is being discussed does not mean that it is, or will become, ACP policy.  Plus, resolutions adopted by the Board of Governors are advisory to the College’s Board of Regents, which has the final authority to set organizational policies.)

So what can we learn from Canada?  I wouldn’t say that my brief visit here makes me an expert on Canada’s socialized healthcare system.  But so far, I haven’t seen masses of extremely ill patients desperately queuing up in long lines to get health care from beleaguered doctors and hospitals, even though this is the image conjured up by critics of Canadian healthcare, such as this description from a conservative Canadian physician  “Thus, at a time when Canada’s population was aging and needed more care, not less, cost-crunching bureaucrats had reduced the size of medical school classes, shuttered hospitals, and capped physician fees, resulting in hundreds of thousands of patients waiting for needed treatment—patients who suffered and, in some cases, died from the delays.” 

Actually, the Canadians I’ve seen in this Pacific Northwest coast city seem pretty darn fit and healthy! But casual observations, of course, aren’t really a fair way to evaluate Canada’s socialized healthcare system.  It is certainly possible that lurking behind a seemingly healthy and contented Canadian population is a system that is denying needed care and causing unnecessary suffering and death. 

So instead of casual observation and conjecture, what does the evidence tell us about Canada’s experience and how does it compare to the United States?

The highly respected, non-partisan Annenberg Public Policy Center runs a website,, that factually evaluates the evidence behind competing public policy claims.  It’s short answer to the question “Is health care better in Canada?” is that “ Wait times are longer in Canada, but health and doctor quality don’t seem to suffer.” 

More specifically, the Annenberg Center reports that “A study by the Commonwealth Fund, a nonpartisan research foundation that promotes improved health care access and quality, showed that 57 percent of adults in Canada who needed a specialist said they waited more than four weeks for an appointment, versus only 23 percent who said so in the U.S. For emergency physician visits, 23 percent of Canadians and 30 percent of Americans said they could get in to see the doctor the same day, but 23 percent of Americans and 36 percent of Canadians waited more than six days. Wait times for elective and non-emergency surgery were even more disparate: Thirty-three percent of Canadians reported a wait time of more than four months, but only 8 percent of Americans had to wait that long. In another study, 27 percent of Canadians said that waiting times were their biggest complaint about their health system, versus only 3 percent of Americans.”

But wait a minute, does Canada’s longer waits for some specialty care result in poorer clinical outcomes and poorer health?  No, says the Center, because “on most measures of patient-reported physician quality, Canada comes out slightly ahead of the U.S. . . Fewer reported physician errors, lab errors, medication errors and duplicate tests north of the border, and Canadians report more satisfaction with their doctors. General health is also better up north, according to the World Health Organization: Life expectancy and healthy life expectancy are both higher in Canada; infant mortality is lower, and maternal mortality is significantly lower. There are fewer deaths from non-communicable diseases, cardiovascular diseases and injuries in Canada, though marginally more deaths from cancer. It’s not clear how much of the divergence is attributable to medical care, rather than other standard-of-living differences between the two countries . . . But these statistics simply don’t support the notion that universal, single-payer health care is crippling the health of Canadian citizens compared with that of U.S. citizens.”

And the Center reports that both the Canadian or U.S. healthcare “score low on health measures compared with other industrialized nations.  “In the Commonwealth Fund’s overall ranking of health system performance, Canada came in fifth and the U.S. came in sixth, out of six countries. On the other hand, the WHO’s 2000 World Health Report gave Canada a slightly better review, ranking it 30th for overall health system performance – above three of the other countries from the Commonwealth study (Australia, New Zealand and the U.S.) but below the other two (the U.K. and Germany). All of these countries, except the U.S., have publicly funded health care, as does every major country in the WHO’s top ten.”

My take-away is that Canada’s system, like the U.S, has strengths and weaknesses.  Canada isn’t the healthcare Nirvana that some liberals believe it to be, but neither is it the healthcare hell that conservatives describe.  It is a system that covers everyone, with lower administrative costs and at a much lower overall cost than the United States, with longer waits for some care than U.S. residents are accustomed to, but with comparable (and in some cases better) outcomes.  The U.S. provides coverage to only 85% of its residents, leaving 46 million without health insurance.  We don’t wait as long for care as our northern neighbors, but our outcomes are no better (and in some cases worse) and it costs us much, much more.  Obamacare would take us a step closer to Canada, in the sense of extending coverage to 92% of U.S. residents, but through a decidedly non-socialistic model of subsidized private and public health coverage, at a much higher cost.

Today’s questions:  What is your view of single payer healthcare and the Canadian healthcare system?  Do you foresee it ever being adopted by the U.S.?


ryanjo said...

I wonder if some of those healthly looking Canadians you saw might have visited the US hospital across the border instead of waiting in the line ( for for the Canadian system to treat them (

Thanks to Obamacare, we may soon get one experience here in the US that Canadians know all too well -- lengthy waits in the ER ( With millions more insured with tax dollars, and no primary care docs to see them, our ERs should soon be standing room only. Hmm, I wonder if patients had to actually pay some first dollar care for their ER visit? Oh, sorry, against ACP principles to ask patients to be responsible for anything!

Steve Lucas said...

Vancouver is an extraordinary town with a highly educated population earning above average incomes, even by Canadian standards. Add to this a recent influx of Hong Kong Chinese who left when China retook the island and you have a very unique population. There is a tradition of good health in this part of the country.

We need to contrast this with the US reality that good health is something that comes from a pill and every problem needs to be addressed in one doctor visit. We have a culture in the US that states; “ I will do nothing in advance to help my health” and show up at a doctor’s office expecting immediate solutions to problems that have been brought on by years of mistreating their body.

In Canada and the EU medicine is treated like a utility. Something everyone needs and the government regulates it to provide the most service at the least cost to the public. We in the US have taken a different tack in the last 30 years turning all of medicine into a financially based business model. Yes, there are exceptions along with winners and losers. A major looser has been front line doctors and patients.

In Canada the patient with a condition or disease that does not impact the larger population will find it difficult to receive treatment. Specialized surgery is much more common and available in the US.

Given the financial incentives I do not see us being able to regulate medicine back to the utility mindset, let alone come up with some hybrid single payer system. The drive for action by the US patient will keep even evidence based decisions from being adopted as we see in the Sept. 19th, 2012 WSJ article Are Stroke Drugs Better Than Stents? By Thomas M. Burton.

The major stumbling block to restructuring US medical payments are the US patient and their demands for instant service and a marketing industry willing to reinforce this sense of entitlement. We recently saw a young woman, attending an exclusive law school, who can expect to make $160,000 upon graduation, demand the government provide her with free birth control. This birth control became a rallying cry for Obamacare and her sense of entitlement.

I am not a fan of Obamacare, but it has brought about a discussion of the problems and distortions of our medical system. Canada has its own issues as now private clinics are being opened to provide service for those with the money to pay. We have exported our concept of medical care to the rest of the world, and it will be almost impossible to bring the rest of the world’s concept of care to the US.

Steve Lucas

Jay Larson MD said...

The advantage to a single payer system would be redistributing resources to where they are needed. It is obvious that the U.S. needs a much stronger primary care force. With the current RVU/FFS system that will not happen. There is some movement towards shifting money towards primary care, but the movement is slow and inadequate. Only 7% of Medicare payment to physicians went to primary care. 7%!!!! With a single payer there would be consistency in formularies, coverage, and paper work. In our 2 doc office in Montana we deal with over 200 insurance plans and the variance in formularies, coverage and paper work is maddening. With single payer the outrageous costs for medications, procedures, and hospitalizations would be tempered. With single payer, all those currently making big bucks would no longer do so. With that said, single payer does have downsides like who will make the critical decisions? Will a single payer system be adopted in the U.S.? Only after we break the bank using our current system.

Harrison said...

We don't as a country agree on the central problem with our health care system and so we don't have much hope for agreeing on a solution.

If we agree on the fact that not having health insurance results in poor health outcomes and more morbidity and mortality, then we could agree that the Affordable Care Act is a step in the right direction.
It is inadequate.
A Canadian style single payer system would help that.
But we don't agree on that as the problem.
The Republican party largely considers that to be a choice and they firmly believe that uninsured people get care they refuse to believe the observational data that their health outcomes are worse -- or at least they refuse to believe that the lack of insurance is the cause of the poor outcomes.

That will only change if the numbers of the uninsured and under insured rise to levels that are headline making on their own.
Not soon.

The other problem that we can all agree on is that health care costs are too high.
But there is no agreement on how to help that.
The fear of a single payer system is that the inflation will be addressed by price controls.
The burden will fall on the industry and the savings will be lower margins for hospitals, lay offs of staff, and lower compensations for physician services.

I think that the Affordable Care Act is a pragmatic step in the right direction.
It won't usher in a single payer system.
It might allow for mechanisms to change the cost inflation curves.

It will all take time.

We are far from even agreeing on which problem we want to address.


Steve Lucas said...

This link is from the Sunday September 30,2012 Toronto Sun electronic edition:

Steve Lucas