Saturday, September 30, 2006

Sara's Sunday Rant

by Sara Robinson

Sunday's usually a slow blogging day here at Orcinus, so I thought I'd take a break from the usual topics and hold forth on something that's a little closer to home.

There was a lively and rather rancorous debate going on over at Alternet earlier this week over whether or not America should join the rest of the world's grown-up nations and provide single-payer health care to everyone. As usually happens, Canada got dragged into the fracas, shoved around by both sides as either an exemplar or a warning -- and, along the way, covered with the obfuscating dust of so many willful misconceptions that the truth is virtually unrecognizeable in the mess.

As a health-care-card-carrying Canadian resident and uninsured American citizen who regularly sees doctors on both sides of the border, I'm in a unique position to address the pros and cons of both systems first-hand. If the health-care debates are going to begin again in the US -- and it's way past high time they should -- then let's please start with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here. Here are a few things y'all need to have the straight goods on before this goes any further.

1. Canada's health care system is "socialized medicine."
False. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that there's one insurer: the provincial government.

This alone reduces the cost and increases the quality of care on about a dozen different fronts. Doctors don't have to charge extra fees to cover the salary of a full-time staffer to deal with several hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most doctors get by quite nicely with just one office assistant, who cheefully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.

Nor do Canadian docs spend half their days on the phone cajoling insurance company bean counters into doing the right thing by their patients. (When is one of those people going to be sued for practicing medicine without a license?) All the invoices go to one place; and the vast majority are simply paid -- quietly, quickly, and without hassle. There is no runaround. There are no fights. Appointments aren't interrupted by vexing phone calls. Care is seldom denied (because everybody knows the rules). They put the bills through online, get their checks on time, see their patients on schedule, and go home in time for dinner.

One unsurprising side effect of all this is that the doctors I see here tend to be more focused, more relaxed, more generous with their time, more up-to-date in their specialties, and overall much less distracted from the real work of doctoring. You don't really realize how much stress the American doctor-insurer fights put on the day-to-day quality of care until you see doctors who don't operate under that stress, because they never have to fight those battles at all. They seem to enjoy their jobs.

2. Government-run health care is inherently less efficient -- because governments themselves are inherently less efficient.
False. There is no logical way that a private system can be more efficient and pay eight-figure CEO compensation packages and still make a profit for shareholders. And, sure enough, the absurdity of this notion is borne out by every available real-world example in existence -- both within America, and abroad.

America's private-sector health care system spends two to three times more on administrative costs than the single-payer systems of Canada, France, Sweden, or any other nation with universal care. It's also considerably less efficient than the country's two largest state-funded systems, the VA and Medicare. If this be government inefficiency, let's make the most of it.

3. Wait times in Canada are horrendous.
True and False -- depending on which province you live in, and what's wrong with you. Canada's health care structure runs on federal guidelines that ensure uniform standards of care -- but are administrated as separate systems by the various provinces. Some provinces don't plan their facilities as well; in those, you can have waits. Some do better. As a general rule, the farther north you live, the harder it is to get to care, simply because the doctors and hospitals are concentrated in the south. But that's just as true in any rural county in the U.S.

You can hear the bitching about it no matter where you live, though. Even though the percentage of Canadians who'd consider giving up their beloved system consistently languishes in the single digits (when asked to name the Greatest Canadian in history two years ago, Canadians -- in a broad national consensus -- gave the honor to Tommy Douglas, the Prime Minister who set up the current system. And no, it had nothing to do with the fact that he was also Kiefer Sutherland's grandpa.), bellyaching about health care is still unofficially Canada's third national sport after curling and hockey. And for the country's newspapers, it's a prime watchdogging opportunity. Any little thing goes sideways at the local hospital, and it's on the front pages the next day. The American system might benefit from this kind of constant scrutiny: it's one of the things that keeps the quality high. But it also makes people think it's worse than it is.

Critics would also do well to remember that the American system is not exactly instant-on, either. When I lived in California, I had excellent insurance, and got my care through one of the best univeristy-based systems in the nation. Yet I routinely had to wait anywhere from six to twelve weeks to get in to see a specialist. Non-emergency surgical waits could be anywhere from four weeks to four months. After two years in the BC system, I'm finding the experience to be pretty much exactly comparable. My son got a needed ear surgery in four weeks; I'll get a knee repair in about four months. The notable exception is MRIs, which were easy in California, but can take many months to get here. Other than that, it's no bloody different.

Here's the way I keep it in perspective. In America, a lucky employee with gold-plated employer-based coverage may well get access to A-level care (though that level of coverage becoming rarer by the month, even among the professional classes). As the Alternet article makes clear, about 50 million under-insured Americans are barely scraping by with C or D-level care; and the nearly 50 million with no insurance at all get next to no care whatsoever. Worst of all: 18,000 Americans die every year due to lack of access to healthcare.

In Canada, everybody gets at least B-level care, pretty consistently across the board -- and, on occasion, quite a bit better than that. (I've got an appointment this week with a Canadian doctor who is one of the dozen or so worldwide leaders in his specialty. And Canada boasts at least four medical schools that are on par with the best American schools when it comes to both education and research.) You might not like those odds if you're one of the shrinking handful of Americans who's used to A-level care; but if that's not you, you'd be getting a much better deal in Canada. And (scare stories notwithstanding), it's extremely rare for a Canadian to die because he or she can't get access to care. It may happen -- but you'd hear the hollering all the way to Inuvik if was happening anything like 1800 times per year, let alone 18,000.

4. Canada's care plan only covers the basics. You're still on your own for any extras, including prescription drugs. And you still have to pay for it.
True -- but not as big an issue as you might think. The province does charge a small monthly premium -- ours is $108/month for the whole family -- for the basic coverage. The premium is waived for people on public assistance or disability.

"The basics" covered by this plan include 100% of all doctor's fees, ambulance fares, tests, and hospitalization charges -- in other words, the really big-ticket items that routinely drive American families into bankruptcy. It doesn't include medical equipment, drugs, physical therapy or chiropractic care, dental, vision, and so on; and if you want a private or semi-private room, that costs extra (though less than you'd pay for a room in a middling hotel). That other stuff does add up; but it's sure easier to afford if you're not paying for the big stuff, too. And, as every American knows by now, drugs aren't as expensive here, either.

Even at that, most families have some form of supplemental insurance that covers all these extras, which brings overall coverage to a level that meets or exceeds the coverage you'd get working for a large, well-insured company in the US. Top-quality add-on policies typically run in the ballpark of $75-100 per person in a family per month -- call it $300-400 for a family of four on an individual plan. On a group plan, it's cheap enough that even smaller employers can afford to offer these policies as a standard benefit (and will often take over payments on your monthly provincial premium as well). When you add this in, your average working Canadian has free coverage equal to the best policies now only offered at a few of America's largest corporations.

5. You have to wait forever to get a family doctor.
Sheesh. Somebody, somewhere, is getting paid a lot of money to make this stuff up. There are any number of first-rate GPs in our neighborhood who are taking new patients. And if you don't have a working relationship with one, but need to see a doctor now, there are 24-hour urgent care clinics in most neighborhoods that will usually get you in and out on the minor stuff in under an hour.

No doubt that it's harder if you live out in the territories. But that's just as true in the U.S. -- and in America, the government won't pay the airfare for rural folk to come down to the city for treatment like it does here.

6. Single-payer health care will make America less competitive.
False. I can't believe people still have the gall to argue this point, but apparently, they do. It's wrong for at least five good reasons.

First: it's no secret that public health care is making Canada a more attractive business environment for large manufacturers, who typically have very high insurance overhead. Toyota and GM have both moved plants to Canada in recent years, in large part to avoid the spiraling costs of insuring American workers. (Toyota also cited Canada's better-educated workers, but education is another rant for another Sunday.) This has been worked over in the press for a couple years -- and should be enough to put an end to this ridiculous assertion all on its own. But wait! There's more....

Second: Being relieved of insurance worries also makes individual citizens more competitive, too. How would your life choices change if you didn't have to worry about health care? Would you go back to school and get your PhD in lepidoptery? Start a blog -- or a business? Work part-time and travel? Tell your boss where he can stick it, and spend some time at home with your kids? Countries with universal coverage free up their citizens to take advantage of personal opportunities that, in the long run, stimulate the economy and create a more skilled, traveled, educated, and fulfilled workforce. Americans, on the other hand, routinely stay chained to jobs they hate -- and pass over chances to expand their horizons and their fortunes -- because they can't afford to jeopardize their health care coverage. The loss is to each of us individually, and to the long-term strength of the economy as a whole.

Third: When families are bankrupted by medical bills, or impoverished when a working member is put out of commission because they can't afford proper care, or simply break down and fall apart under the stress of debt and illness, it's not long before the country's entire social fabric begins to show the wear and tear -- along with the sense of optimism and the common good required for a democracy to function. I've often been impressed by the very tangible sense of civic pride and shared effort my Canadian neighbors have in the fact that they're taking the best possible care of their own, regardless of status, age, or ethnicity. Every encounter with the medical system reminds them that they're all in this together. They wouldn't admit to being proud of their system -- they prefer to leave boastful expressions of pride to their southern neighbors -- but they are, and rightly so.

Part of what makes a country competitive is its own commitment to the common good. A medical system that routinely drives families into bankruptcy or divorce court is actively destroying, rather than adding to, the essential social capital that makes the whole society function.

Fourth: Decades of deferred medical care are starting to catch up with Americans. We're seeing it on many fronts: infant mortality, lifespan, cancer rates, heart disease rates, and increased diabetes. On most of the major markers of public health, America is nowhere near the top tier anymore. In a few areas, there are small former Communist countries doing better than we are. Any country that's spending more and getting less is neither efficient nor competitive. Business relies on healthy workers who aren't distracted by their own illness, or the illness of a family member. An uninsured, increasingly unhealthy workforce is in no position to compete on equal terms with a strong, healthy one that's getting the care it deserves.

Fifth: Our every-man-for-himself attitude toward health care is a national security threat on a par with unsecured ports. In Canada, people go see the doctor if they're sick for more than a day or two. It was this easy access to early treatment, along with the much tighter public health matrix that enables doctors to share information quickly, that allowed the country's health care system to detect the 2003 SARS epidemics in Toronto and Vancouver while they were still very localized, act within hours to stop them before the disease spread any further, and track down and treat exposed people before they got too sick to be helped. In both cases, the system worked flawlessly. The epidemic was stopped within days and quashed entirely in under a month, potentially saving of millions of lives.

In the U.S., that same epidemic might easily have gone unnoticed for critical days and weeks. If the first people to get sick were among the one-third of the country that doesn't have adequate insurance, they probably would have toughed it out a few extra days before finally dragging their half-dead carcasses into an ER somewhere. Not only would they be much farther along in the course of the disease -- greatly increasing their own mortality risk -- every one of them could have infected dozens or even hundreds of other people in the meantime, accelerating the spread of the epidemic. Worse: the underfunded public health system might have taken several days to piece together the whole picture of an epidemic; and perhaps another week or two might have passed before the right-wingers in charge (having thrown out the science-based management plans thoughtfully developed by the bureaucracy) cooked up some kind of half-assed ideology-driven decision about how to proceed. (It would, of course, involve spectacular amounts of lying.) By that point, tens of millions could have been infected, leading to a death toll that would make 9/11 and Katrina look like minor statistical blips.

Think about superbugs and the ongoing waves of immunological imports from the world's swamps and jungles. Think about terrorists with bioweapons. And then think again about the undeniable fact that every single underinsured American is a gaping hole in the safety net that protects us all from a catastrophic epidemic. This really is one of those cases in which none of us are safe as long as even one of us is left at risk. And from a purely economic standpoint: would you want to invest in a country where there was a significant risk that an epidemic or a bio-attack, managed by incompetent officials, might force you to shut down your business at a moment's notice?

7. This all sounds great -- but the taxes to cover it are just unaffordable.
False. On one hand, our annual Canadian tax bite runs about 10% higher than our U.S. taxes did. On the other, we're not paying out the equivalent of two new car payments every month to keep the family insured here. When you balance out the difference, we're actually money ahead.

And, frankly, it feels a whole lot better to know my taxes are taking care of my fellow Canadians than it does to have it buying bombs to drop on Iraqi towns, a fully-equipped CIA gulag, and Baghdad pizza deliveries via Halliburton. It's hard to become a worldwide empire when you're putting half your tax revenue into hospitals and doctors, as Canada does. Likewise, it's hard to insure your citizens when half your tax revenue is going to feed your war machine. In a very real sense, America has chosen to secure its oil supply at the cost of its own citizens' health. The more we spend on the former, the less we have for the latter. And our own relative health -- both physical and economic -- is starting to show the consequences of that choice. Ultimately, all these things are connected: by making ourselves energy independent, we might not only make ourselves more secure, we'll also finally be able to invest in the kind of health care that will make us truly competitive in the world community.

OK, that's my Sunday rant. Don't listen to the recycled 1993 Harry and Louise bullshit. The only part of that party line that's not a deliberate distortion is the part that's flat out not true. It is true that Canada's system is not the same as the U.S. system. It's designed to deliver a somewhat different product, to a population that has somewhat different expectations. But the end result is that the vast majority of people get the vast majority of what they need the vast majority of the time.

I look forward to a day when Americans can hold their heads just as high, and boast that their system can deliver that kind of reliable, consistent care, too. Unfortunately, until we start dealing with facts instead of fear, that day is only going to keep getting farther away.

Update -- Oh, and one more myth: If you buy Canadian drugs, they're not the same. Another falsehood, of course. They are exactly the same drugs, made by the same pharmcos, often in the same factories. Although they're sometimes dispensed a little differently, and there are weird wrinkles. My favorite one is that you cannot buy Aleve in Canada: naproxyn sodium is strictly Rx. On the other hand, Tylenol with codeine is strictly regulated in the U.S., but any pharmacist in Canada will sell you a bottle for the asking. Plan B is also OTC here: no Rx required, no doctor, no waiting, and no moralizing. (Abortion, on the other hand, varies wildly from province to province, generally getting more problematic the farther East (and more Catholic) you go.)

Here in BC, the province sponsors an independent research panel that advises doctors on which drugs in any class are actually most effective. This is great, because they can tell you if the new miracle drug is really worth the extra cost; or the old standby is still the better choice. Not only does this help keep costs down, it makes doctors much more skeptical and choosy in the face of drug reps. Science in the service of better care. Who'd believe it?

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