I read a funny article over at the American Spectator site. It's basic premise is that politics is the art of the stupid. This paragraph caught my eye:
Medicine costs more today because it does more. I was just reading Robert Stone's Prime Green, a memoir of the 1960s, in which he suffered from blurred vision and went to the Stanford Medical School clinic, where some of the best doctors in the world drilled two holes in his skull to find out whether he has a brain tumor. (He didn't.) That was before MRIs. Yet in 1993 Hillary Clinton was telling us about all the money "wasted" on high-tech equipment in the U.S. Every hospital in America wanted its own MRI machine while in Canada they got by with four for the whole country. Is this the amateur hour or what?
It prompted me to try to validate the statistic and see if I could find some current ratios between Canada and the US. Guess what? I found something better.
Cue the Queue
There is a Canadian Institute for Health Information (CIHI). Their web site publishes many, many statistics. Here's the fun part. Under Research and Reports, there is a sub-menu for Wait Times. This section is solely dedicated to measuring the length of time that patients wait for treatment.
Soak that in for a minute. While healthcare discussion in the US is always about measuring costs, Canada is focused on measuring waiting. There is not even a sub-menu for costs at the CIHI site.
There is, however, an April 2009 report of comparative wait times across the provinces. Here is the opening paragraph in the PDF report:
First ministers met in the fall of 2004. They listed timely access to quality care at the top of their collective agenda. Together, they agreed to focus on better management of wait times and on reducing waits that are longer than medically acceptable in five priority areas: cancer, heart, diagnostic imaging, joint replacement and sight restoration. To assist in achieving these goals provinces agreed to establish and report on progress for specific wait time indicators and benchmarks. As part of this plan, the Canadian Institute for Health Information (CIHI) was asked to report on progress on wait times across jurisdictions.
Reading between the lines, I don't think we can assume that wait times are great in all categories but these five. They picked these five areas to bring focus to their efforts. Elsewhere on site, it was noted that the plan to improve wait times in these areas was a 10 year (!) plan. I guess they'll be waiting on the improvements in waiting.
I did not read the whole report but I did find this table summarizing current wait times. This shows whether 75% of patients got their treatment within the benchmark.
Observations:
First, it is assumed from the get-go that 1 in 4 people will not get their treatment within the benchmark. Think of three other people you know and spin the bottle to see who will wait the longest.
Second, for knee replacement, only 3 of the 10 provinces are meeting the benchmark of six months. Imagine walking around for 6+ months on a knee that needs replacing. Things are a little better for cataract surgery and a little more better for hip replacements.
Lastly, for Coronary Artery Bypass Surgery, all provinces are meeting the benchmark. Sounds good, except, similar to knee and hip replacements, the benchmark is six months. Now, I believe the measurement excludes emergencies so clearly there would be some surgeries scheduled very quick and they would not get included here. However, if you have heart disease, you would essentially be trusting the doctor's judgment that you can wait six or more months for your surgery without having a heart attack. Some people like to gamble and can probably handle the action. Others? Maybe not.
What Are We Waiting For!?!?
Healthcare reform proponents feel like they have been waiting a long time for their political goal to come true. They may find that achieveing their goal only results in a new kind of waiting. My suspicion is that they will find waiting for a needed surgery a lot more frustrating.
TIP:
Enter the amount, and click "Tip" to submit!
Brie
libertarius
Kenn Jacobine
apache savage
VIGILOCANIS
Blackflon
Salon.com
Comments
I do think it is important for people to think about how time is not recoverable or fungible but money is. Businesses do things faster when they can make money doing it. When it doesn't matter then they go slower.
Another story was that of a teenage girl -- with a family history of malignant melanoma, no less -- who had to wait a full year for a referral to a dermatologist after discovering a suspicious mole on her back. By the time she was seen, the melanoma had metastasized and she died shortly thereafter. At least the government was spared the costs of treating her .
If you love the Post Office, the Department of Motor Vehicles, and the I.R.S. (and, hey, what about that Cash-For-Clunkers program?), then you'll love government-run healthcare. Especially when more and more physicians retire early and fewer and fewer bright young people opt to pursue medicine as a rewarding and lucrative career.
OK, stepping down from my soapbox now ;-)
Ok, let's talk about waiting times in the U.S. for knee replacement and cataract surgery. Here's my experience:
I'm currently unemployed and paying $750 a month for COBRA benefits. So I have insurance, but between the premium, deductibles, and copays I can't afford to get much done.
I have arthritis in both knees, take narcotics four times a day and walk with braces on both legs. You say "Imagine walking around for 6+ months on a knee that needs replacing." I don't have to imagine it. I live it, not with one but two knees. I've been living it for almost a year now, and even when I'm employed I have no idea when I'll be able to get surgery. I'll have to wait until I have enough sick time to cover the surgery and rehab. My guess is that, if all goes well, I'll get surgery on one knee maybe two or three years from now. Until then, for me going grocery shopping for an hour is a major event, and even with narcotics I'm crippled up for hours afterward. I only hope that my joints don't completely collapse before I get surgery.
Let's talk about cataracts. As I write this I'm looking at the computer screen with only one eye. That's because I'm half blind in the other one from a cataract. The surgery only takes 30 minutes, but my cost would be around $2,000. So I have basically seen the world through one eye for the last six months, and I can't afford to get the other one fixed until I get a job, and hopefully better insurance.
So when I hear about people in Canada waiting six months for a knee replacement, or 16 weeks for cataract surgery, that sounds like heaven on earth to me. And I'm lucky enough to have insurance; people who don't are in far worse shape.
And by the way, there's no government agency tracking MY waiting time.
Because of the ongoing bleeding and the vision-deterioration this is a time-sensitive condition.
On July 10th the ophthalmologist referred the patient to another doctor within the same department to do the laser procedure. On that day the next available time slot was 14 WEEKS LATER, on October 16.
The patient lives in one of the most technologically advanced areas of the country (21 ophthalmologists are listed on the eye department's web page) and is covered by a good-quality PPO insurance.
If it takes 14 weeks and will cost quite some money to the patient, then a 16 weeks waiting period in Canada for a cataract surgery (which, I suspect, is not time sensitive) IS EXCELLENT!
So we have more MRI's? So what? Life expectancy in Canada is higher than it is here. So you're basically just repeating the arguments of the proponents of national health insurance: that we spend more money on expensive medical interventions without a corresponding increase in quality.
And please don't give us any bromides about "I don't want the government involved in health care." 58% of health care costs in this country are underwritten by the taxpayers. On a per capita basis, that's more than TOTAL spending in all but three other countries. It's time we started demanding the money be spent in a rational manner.
Healthcare reform proponents... may find that achieveing their goal only results in a new kind of waiting. My suspicion is that they will find waiting for a needed surgery a lot more frustrating.
To say this, we have to know how long people are waiting in the U.S. now. There's anecdotal evidence that waits are shorter, with some Canadians coming over the border for surgeries and treatments, but it's not fair to make a comparison without real numbers on both sides. (The American numbers might be higher than intuition tells us--we'd also want to to factor in Americans who put off surgeries and treatments because they can't afford it.)
We can't look at a set of numbers and say, "We don't want to go there, do we?" without knowing how far away we are, or even whethere we're there already. I mean, if we make the (probably unrealistic but straightforward) assumptions that (a) the need for the treatments listed above is evenly distributed over people with and without health insurance, and (b) the 18% of Americans who don't have health insurance simply won't get those treatments, then we're already just 7% away from that 75% cut-off the Canadian statistics are based on, across the board. Consider estimates that some 40% of Americans have inadequate health insurance, and things look even more ambiguous.
Of course, this is just speculation. But it's meant to illustrate why numbers on one side of a comparison but not the other don't tell us very much.
You can come up with horror stories of individuals and clinics and whatever anywhere. What you won't come up with in Canada are horror stories like Mishima's - people with deteriorating conditions because they can't afford treatment.
Think of the money that goes to insurance companies in the U.S. in return for ... what?
And for those who say, gee, think of the incompetent government running things - actually, the post office seems to do its job, and who wants to see privatization (with insurance companies as go-betweens) for the fire department, police, roads, restaurant inspection, all the myriad (sorry) services the government provides.
@ montanarose: you are not going to get anywhere with post office analogies.
http://www.huffingtonpost.com/cenk-uygur/is-the-us-military-a-soci_b_252526.html
That's correct. Another thing to consider is that no one is tracking the waiting times of people who don't have insurance. So around 45 million people aren't having their waiting times tracked. What is the waiting time for a hip replacement for an American who doesn't have health insurance? No one knows, and those figures are not included in any U.S. statistics.
As to the specifics on knee replacement, there is a study from the 1990's published in the New England Journal of Medicine that concluded that wait times in Ontario were longer than the US. Yes, that is dated but it might be reasonable to think that things are not much better since the Canadian government is targeting this exact surgery for wait time improvement.
On some specifics, Mishima, I definitely agree that having healthcare tied to employment is a significant weakness in the US system. I want change too. However, we have to have a good reason to believe that the change we make will be better. As many of my other posts have described, I believe that less government involvement, not more, gives us a better chance to have more responsive, lower cost healthcare.
Rob, I'm glad you caught that I was careful in my language. Sharp OSer's like yourself keep me on my toes. I try not to saw myself off my own branch. :-)
And there have been deaths for lack of coverage, like that poor girl that needed the transplant and couldn't get it. She died. That's all in America.
So, I've had some very long wait times here. But, you know, I got the bill, the very high bill, really quickly.
And the police, the fire department and the post office do a decent job overall I think, in reference to someone here who mentioned our socialized services. And the IRS has fallen in line, once someone kicked their collective butt.
And look at the numbers and tell me how great the US health care system is; the US is rated 28th in life expectancy and 29th in infant immortality. Countries like Jordan do better than we do, and we get this dismal score despite the fact that we spend 16% of GDP on health care.
And Myriad; zing!!! Just because something's done by the private sector doesn't mean it's automatically better, and you'd be hard-pressed to find better examples of that than looking at taxpayer money being thrown down the gullet of Halliburton and KBR.
bottom line with the Canuck system:
can you choose your own doctor? yes
Are there wait times- sometimes
Is there a bill- nope, never.
Assuming the above, how much more in taxes are you willing to pay so that everyone in poor foreign countries can have access to some minimum standard of healthcare?
That pride is something that we would not normally harp on but, as I said, when "critics of Canadian healthcare" in the U.S. cherry pick anecdotes or complain about the statistics gathered by Canadian government agencies to measure and improve wait times, we tend to get resentful.
That is EXACTLY what I believe. And please explain to me how that means I'm saying we should be "willing to pay so that everyone in poor foreign countries can have access to some minimum standard of healthcare?" This discussion is about providing health care to the citizens of this country; by what pretzel logic do you twist that to mean I'm saying we need to pay for health care for other nations?
Just recently she had a very minor procedure done. Her primary care doctor saw her first and then set up the appointment with a specialist - it took 2 weeks. Her visit time was 15 minutes for the procedure was 15 minutes.
Today she pays $50 to see any doctor for any reason. Her medication costs her pennies a day (I pay dollars a day for the same drugs. )
What is her marvelous plan? My mother served in the Navy in the 1960s. Her health care is paid for by the government. Seems to work brilliantly if you ask me. Better than any care I've ever received through a private plan. I look forward to a government takeover.
However, providing health care and drinking water to everyone, regardless of ability to pay: is the decent thing to do; it is to the benefit of all society to do so (just as it benefits society to provide police protection for all people); and, judging by other developed western countries, it is cheaper for the government to provide health insurance to everyone, and it has better outcomes, compared to the current health care system in the U.S.
If it's the decent thing to do, to the benefit of society, and more efficient, that seems like a good case for the government to be involved.
And yes, the rich would pay much more than the poor. That is the way taxes work. There are ideological arguments to be made in favour of a flat tax, but I don't think the health care debate should be conflated with the tax debate. The fact that the rich pay more toward government health insurance than the poor is not a disadvantage of that system - it is just a fact of any government program with a progressive taxation regime.
Here's what I think: Similar to Don's comment, I do not believe that healthcare is an entitlement. It is physical good/service and there will always be inherent constraints on how much can exist. Free speech and freedom of religion has no such limit. Everyone has the same amount the second they are born.
Additionally, because healthcare is constantly changing in quality, it would be very difficult to articulate what exactly you are entitled too. Until MRI machines were invented, an entitlement to use one could not exist.
Allocating healthcare is no different than allocating any other good or service. Free markets are the most efficient at allocating based on price. But as Don says, sometimes we value things other than price efficiency. This causes us to decide that we will accept a less efficient allocation (and higher prices) to spread the allocation around.
You can join me in helping the poor by donating to Trickle-up.org and loaning money overseas through Kiva.org.
I don't have health insurance; I can't afford it. How long will my wait be if I need a procedure which I can't pay cash for, which is pretty much all of 'em?
And look at the numbers and tell me how great the US health care system is; the US is rated 28th in life expectancy and 29th in infant immortality. Countries like Jordan do better than we do, and we get this dismal score despite the fact that we spend 16% of GDP on health care. We spend more money per capita for health care than anyone on the planet, yet we have a population that's less healthy than nations which spend less. How do you square that with your contention that "Free markets are the most efficient at allocating based on price?"
I don't see where you get the higher prices - we in Canada pay the same or less over-all for health care, and cover everyone (which makes it less expensive per capita).
As for free markets - that perhaps should see doctors competing with each other and keeping their fees down. As it is, it's insurance companies ... and for the life of me I cannot see what service they provide, except to themselves. Our system operates quite nicely without them, and we can put directly into health care the money they would be siphoning off.
And rich nations do, thru governments and NGOs, help with health care in poor countries. More effectively, trade and having manufacture abroad puts money into their economies, which enable them to get better health care. Indeed, we are draining ourselves to help the 'developing' countries (at least that's one effect - the intention, of course, was entirely to make money on the part of corporations). One of Obama's arguments, and I think it's a good one, is that America would become more productive and competitive if the population were healthy and secure in their health care.
And, I did not put words in your mouth. I challenged you to explain what you really meant by asserting that something is an entitlement.
Jeez...
Nanatehay, sure, if you are dead broke, then yes, you will wait longer for non-emergency care. Would I like things to be better? Yes. But, as said elsewhere, we have to judge what gives us the best chance to make things better. I do not believe that having the government take a more powerful role is likely to result in better service at lower cost. CBO appears to believe the costs will go up. If the costs go up, it is likely that service will go down as gatekeepers try harder to ration the remaining service.
I have written other posts that offer different ways of looking at this.
I am off to bed so I will check back tomorrow evening and add more comments as seems appropriate. I do not necessarily comment back to everybody because between my posts and the comments I do make, I think people can figure out where I am coming from. Many comments from others also can stand on their own.
"if you are dead broke, then yes, you will wait longer for non-emergency care."
I will wait longer for non-emergency care? How long exactly will I have to wait for non-emergency care? Until I can raise the necessary money to pay for it? Until I die? Which one is more likely to happen first I wonder? See, that's a question millions of Americans have to ask themselves whenever they look at the possibility of getting sick, which is why all this talk of benchmarks and wait times and gatekeepers is, as Drew rightly pointed out, irrelevant. Or at least it's irrelevant to me and the tens of millions of uninsured Americans who are basically written off by our current health care "system." Gatekeepers? WTF. Talk to me about gatekeepers if you ever happen to be dying from a condition which you can't afford to have treated because you're uninsured. There's no better gatekeeper out there than a system which values people based on how much money they have.
Bypasses do have survival benefit in certain patient subclasses, particularly diabetics with blockages in 3 or move vessels, and people with left main coronary artery disease.
Now to the larger point. Wait time comparisons with Canada always focus on surgeries. But there is something else to consider -- the wait time to see a doctor when you are sick. If you wake up vomiting, how long will it take you to be seen by your regular doctor? What is your wait time to see a primary care doc when you are sick.
The answer is that in Canada, Britain and France, most people who are sick get to see their doctors the same day or the next day. In the U.S., according to a study reported in USA Today in June, average wait to see a family doctor is 49 days in Boston, 19 days in New York, 24 days in Los Angeles.
Put another way, in the U.S. we spend huge dollars to get people easy access to the MRI or the surgery suite, but we don't invest anything in primary care. It's easier to get a brain tumor removed in the U.S. then it is to find a doc to give you a tetanus shot.
I like the Canadian way better. Canadians have obviously made a conscious decision to make it easier to get routine visits, which patients need more often, than expensive surgeries and tests, which people don't need as much.
We Americans, on the other hand, have decided to let the bread and milk aisles run empty, while locking up an endless supply of caviar.
I was oversimplifying things a bit. Overall, bypass surgery offers no survival advantage as compared to noninvasive treatment. It does benefit the sickest three percent of patients -- but that means the other ninety-seven percent are not benefiting.
A study published in Lancet found that angioplasty resulted in a HIGHER mortality rate than those given nonivasive treatment.
Lancet 1997 350:461-468
Thanks for giving me the chance to clarify this.
Look, the argument is not about time. The argument is about who gets to PAY THE DOCTOR and therefore, who gets say in what happens. We all know, if you have insurance, who pays the Dr. You and the insurance company, unless the insurance company thinks something is wrongly priced, or "experimental" or any other method used to deny care. That is what they do. Paying care is a loss to the insurance company, denying it pads the bottom line.
The government, on the other hand, would provide a basic level of services and if you want more, you can either self fund or buy insurance. If everyone has basic needs met and insurance companies can only sell policies to cover above that (the German system, which has worked well since the late 1800's) you force the companies into real competition. Isnt that what Republicans want? A market driven system designed to lower costs?
I heard a wonderful analogy the other day about why some people want to keep insurance companies as the sole arbiter of who gets care and who doesn't. Our health care system is like the Titanic. If you have money, you are "on deck" and you get a space in the lifeboats. If you don't (the poor Brits and Irish trying to come to America) you are in steerage. You are locked down below. Good luck.
As a broader comment, yes, it is unfair that medical care is not free... as every other thing in the world like food, shelter, etc are not free. As bad as your plight may seem, I perceive there are millions, maybe billions, far worse off in the world who would gladly trade places.
The best thing we can do for ourselves and those others is continue to be successful and create wealth. I believe Obama's policies will reduce the wealth of this country. It will hurt us and it will hurt non-Americans too because of how important America is in driving the global economy. Plus, substituting an autocracy like China as the dominant driver in the world does not strike me as a good prescription to produce a better result.
As a note, I have posted about ways to get to a form of universal coverage while creating a larger consumer driven market for healthcare. You would be covered but you might be in a below average plan where wait times are higher than an above average plan that wealthier people would be free to buy.
http://open.salon.com/blog/mcgarrett50/2009/06/14/healthcare_debate_2_is_compromise_possible_wmusic