A cautionary tale

One point I've made is that nationalized health systems can be cheaper because they deny access to their system of "universal" care. Here is one such tale.

I do find it absurd that the advocates of state-run care argue that it will provide "universal" care when it does no such thing. As far as I know every single nationalized health system rations care. What they mean by "universal" care is that everyone gets some care just not all the care they need. But that is also the case in the United States under the current, screwed-up, mixed system of care.

Socialized health care: the equal right to wait, and wait, and wait.

While Americans were debating the Obama administrations attempt to have government grab the health care sector no one was paying attention to the news from Canada. Canada is one of those state-controlled health care systems that is lauded and praised by those who want a form of health care fascism in America.

The article in question appeared in the Vancouver Sun and mentioned a document that was leaked from the local Health Authority. In Canada, health care is run by the provinces on behalf of the federal government. I should mention that a couple of years ago the Canadian Supreme Court legalized private health insurance, which had been banned by the government, saying that the government was doing such a poor job of providing care, that banning private care on top of what they were doing, was a violation of the rights of Canadians. Since the state was unable to provide decent health care as promised it could not also ban private care as that put the lives of people at risk.

The document that the Sun mentioned was a report from the health authority on the number one problem of socialized care: the inability to pay for it. The problem is that once you announce care is “free,” by which they don’t actually mean free, just that payments are divorced from consumption, the numbers of people wanting more and more care explodes. The demand for care exceeds the supply of care. That is how it is with any good or service that people desire: demand will always exceed supply.

AS the demand explodes so do the costs. But the big slogan of the advocates of nationalized care is that they offer “cheaper” care. So, with exploding demands they have to ration the care to keep costs down. Unfortunately, as they keep trying to reduce the supply of medicine the demand continues to escalate. That leads to budget shortfalls. They don’t have the funds to pay for it.

The Fraser Health region in British Columbia is facing a $160 million shortfall so they were trying to figure out what health care they could end. The document discussed included more rationing of care. A representative of the New Democrat Party (socialists) said this indicated cuts to: “Diabetes clinics in Delta and Mission, regional maternity and pediatric services, and seniors’ aid and mental health programs….” The bureaucrats admit the report is genuine but say it is misleading to allow the public to read it. They admit discussing “a potential 10-per-cent drop in the number of elective surgeries… and longer waits for MRI scans.” Remember, that under government health care programs they decide what is elective surgery not you, not your physician.

Canada’s Health Minister Kevin Falcon said “We’re in the situation right now where there is no more money” and that cutting care is necessary to keep the system sustainable.

The article mentions one hospital that will be forced to close its emergency ward entirely requiring patents to be taken to hospitals another 20 minutes away.

One way that the state health systems keep costs down is to limit the number of people who can have care at any one time. The result is waiting lists, patients are told they are on the list for treatment or surgery and that in some week’s time they will get the care. If you only have one MRI machine, which is expensive, then only so many people can use it in a day. Reduce the capital expenditure on health care, which socialized systems do, and you end up with patients waiting, and suffering longer, in order to get that care.

In Canada the Wait Time Alliance monitors the waiting lists that result from rationed care. The WTA is not a batch of “right-wingers” or “tea party activists” or whatever other stereotype one may use to describe opponents of nationalized care. It is an alliance of groups like the Canadian Association of Emergency Physicians, Canadian Association of Radiologists, the Canadian Medical Association and ten other associations of health care professionals.

In their June, 2009 report, Unfinished Business: Report Card on Wait Times in Canada, they attempted to measure the average waiting time for patients. Under the Canadian system an individual must first see a family physician. That physician acts as a gatekeeper, you don’t get see a specialist unless you are recommended by your physician. The waiting period includes the time period between seeing your physician to get permission and the time you actually see the specialist. In addition a second layer of waiting is then measure: that is the period between seeing the specialist and having access to treatment. What is not included “is the wait patients may experience to access their family physician or the fact that nearly 5 million Canadians do not have a family doctor.” (p.3)

In particular they tried to measure the waiting time in comparison to “benchmarks” set by the government. WAT, however, notes that the government benchmarks for waiting periods “represent maximum acceptable wait-time targets and should not be viewed as desired wait-time targets.” In other words, the benchmarks the government set for itself are absolute minimum possible before getting a failing grade completely. Sometimes, what the government considers “acceptable” wait-times, are considered highly undesirable by the actual physicians involved. WTA and the Canadian Cardiovascular Society argued that, with cardiac bypass surgery, no more than six weeks should pass from the initial doctor’s visit and surgery. The government is quite happy with a target of 26 weeks. (p. 4)

Even with somewhat loose targets the government system fails: “Based on the… target of 18-weeks from initial referral by a family physician to start of treatment, a majority of patients had wait times that exceeded the 18-week target.” For cancer patients “the median wait for radical (curative) cancer care was 46 days or nearly 7 weeks… the majority of these treatments exceeded the CARO [Canadian Association of Radiation Oncology] benchmark for curative cancer treatment of 4 weeks (2 weeks for the consult wait and 2 weeks for treatment). This is troublesome given the clear link between delay in radiation therapy and a chance of cure.” (p. 7)

This sort of waiting is routine even for emergency treatment. The report said that “the media wait time for patient [in emergency care] presented at the ED to the time they were admitted to an inpatient bed was 19 hours (average is 23.5 hours or nearly one full day,) which is substantially higher than the CTAS [Canadian Triage and Acuity Scale] thresholds (e.g., more than three times the 6 hour guideline for high-level acuity patients). The longer wait for patients to be admitted is often due to the inability to find an available hospital inpatient bed.” That inability is because hospital beds are expensive to maintain (not just the bed but the care that goes with it) and one way to reduce costs is to limit availability to that care by limiting the available of hospital beds.

These wait-times are critical. Whatever flaws the US system has, and most of those are due to political interference, the US stacks up quite well for actual treatment needed and received, compared to Canada. A report by June O’Neill and Dave O’Neill, Health Status, Health Care and Inequality: Canada vs. the U.S., investigates the percentage of people, with particular conditions, receiving care for those conditions in the United States verses Canada. As previously reported here:

In Canada 84.1% of those with high blood pressure were receiving treatment for it. In the United States the number was 88.3%. Those with emphysema or related illnesses are far better off in the US where 72% are receiving treatment versus 52% in Canada. In the US 69.6% of individuals with heart disease receive treatment while in Canada the rate is 67.2%. When it comes to coronary heart disease 84.8% of American sufferers receive treatment as compared to 88.9% of Canadians with the problem. Out of eight conditions they investigated Americans have higher treatment ratios in six categories with Canada leading in asthma and angina. These were for individuals age 18 to 64.

But these differences remain fairly consistent for individuals over the age of 65 as well. The only change was for angina where the U.S. now has a higher treatment rate than Canada: 77.7% to 73%. The report noted that “the U.S. generally performs better with respect to treatment of all conditions except that of asthma.”

What about preventative procedures like PAP smears, mammograms and PSA tests for prostate cancer? Again higher percentages of the American public receive such tests than do Canadians. In the U.S. 88.6% of women ages 40 to 69 have had a mammogram. For Canada it was 72.3%. In the U.S. 74.9% of the woman had the test within the last two years where only 54.7% of Canadian women had a recent test. For PAP smears the rate was, over the last three years, was 86.3% for American woman versus 88.23% for Canadian women. The men get a worse deal in both countries when it comes to testing for prostate cancer. In the same age group, 54.2% of men have been tested while in Canada the rate was an abysmal 16.4%. And testing for colorectal cancer is done, both for men and women, about six times as often in the United States as in Canada.

When the study looked at survival for cancer in both countries they also found that Americans were slightly better off. They looked at the ratio of the mortality rate to the incidence rate for cancers and found that Americans are ahead. They concluded, “in terms of the detection and treatment of cancer, the performance of the U.S. would appear to be somewhat better than Canada’s.”

The use of MRIs and CT scans are also much, much rarer in Canada. Canada has 5.5 MRI scanners per million people as of 2005. The US, in 2004, had 27 per million. When it came to CT scanners the US had 32 per million in 2004 while Canada, for 2005, had 11.3.

Considering that one of the alleged virtues of Canada’s health system is the “equality” factor it is interesting to see that more individuals in the US, with specific conditions, are receiving treatment than do their counterparts in Canada. The report also found that the poor in the United States reported as much, or more health care, than those in Canada did.

Does Canadian health care really stack up so well?

A new study from the National Bureau of Economic Research questions the alleged superiority of Canada’s nationalized health system in comparison to the United States.

In Health Status, Health Care and Inequality: Canada VS. the U.S., June O’Neill and Dave O’Neill, of Baruch College, look at several issues regarding the delivery of health services to the general public and what they found will not particularly please some people.

They first argue that the use of infant mortality rate and life expectancy are very poor measures of health care delivery. We explained some of those reasons here. The NBER report also noted that “infant mortality is strongly linked to low birth weight and to preterm births.” This is important because teen mothers tend to have low weight babies, and the US has the highest teen pregnancy rate of developed nations—almost 3 times that of Canada. That skews the infant mortality rate in favor of Canada, but it not related to the health system.

And, when they look the mortality rates within specific birth weights the US actually does as well, or better than Canada. Canada does better overall because fewer high risk mothers are giving birth to low weight infants. The NBER study says that if weight distribution in Canada were similar to the US the infant mortality rate there would rise to 7.06, which would actually be higher than the rate in the US, which is 6.85. Their advantage is not health care related but due to the lower rate of teen pregnancies.

Similarly, life expectancy is not a gage of health care because it includes things such an accidental deaths and homicides. And, there is the fact that Americans are fat. A third of US females are overweight, while the rate in Canada is 19%. This impacts life expectancy but obesity is not a result of poorer health care. Fewer calories, up to a point obviously, increases life expectancy.

What this paper prefers to look at are actual indicators of health. What percentage of people with a specific illness obtain treatment for that problem. And they looked at the issue of equality in health care. Does the Canadian system actually deliver the same amount of care as it does to less well off as it does to the better off, and how does Canada compare to the U.S.?

In a self reported health survey 62.5% of Canadians, ages 20 -64, said their health was very good or excellent. In the United States the number was 67.5%. For those over the age of 65 it was 38% of Canadians and 40% for Americans. And one reason could be that Canadians, regardless of the single-payer system, were less likely to actually receive treatment.

In Canada 84.1% of those with high blood pressure were receiving treatment for it. In the United States the number was 88.3%. Those with emphysema or related illnesses are far better off in the US, where 72% are receiving treatment versus 52% in Canada. In the US 69.6% of individuals with heart disease receive treatment while in Canada the rate is 67.2%. When it comes to coronary heart disease 84.8% of American sufferers receive treatment as compared to 88.9% of Canadians with the problem. Out of eight conditions investigated Americans have higher treatment ratios in six categories, with Canada leading only in asthma and angina. These were for individuals age 18 to 64.

But, these differences remain fairly consistent for individuals over the age of 65 as well. The only change was for angina, where the U.S. now has a higher treatment rate than Canada: 77.7% to 73%. The report noted that “the U.S. generally performs better with respect to treatment of all conditions except that of asthma.”

What about preventative procedures like PAP smears, mammograms and PSA tests for prostate cancer? Again higher percentages of the American public receive such tests than do Canadians. In the U.S. 88.6% of women ages 40 to 69 have had a mammogram. For Canada it was 72.3%. In the U.S. 74.9% of the woman had the test within the last two years, where only 54.7% of Canadian women had a recent test. For PAP smears the rate was, over the last three years, 86.3% for American woman, versus 88.23% for Canadian women. The men get a worse deal in both countries when it comes to testing for prostate cancer. In the same age group, 54.2% of men have been tested while in Canada the rate was an abysmal 16.4%. And testing for colorectal cancer is done, both for men and women, about six times as often in the United States as in Canada.

When the study looked at survival for cancer in both countries they also found that Americans were slightly better off. They looked at the ratio of the mortality rate to the incidence rate for cancers and found that Americans are ahead. They concluded, “in terms of the detection and treatment of cancer, the performance of the U.S. would appear to be somewhat better than Canada’s.”

The use of MRIs and CT scans are also much, much rarer in Canada. Canada has 5.5 MRI scanners per million people as of 2005. The US, in 2004, had 27 per million. When it came to CT scanners the US had 32 per million in 2004 while Canada, for 2005, had 11.3.

Considering that one of the alleged virtues of Canada’s health system is the “equality” factor it is interesting to see that more individuals in the US, with specific conditions, are receiving treatment than do their counterparts in Canada. The report also found that the poor in the United States reported as much, or more health care, than those in Canada did.

This report also noted that waiting time in Canada for care is significantly longer than in the United States. The absence of care, they contend, is more problematic than the ability to pay for the care. As they note “costs may be more easily overcome than the absence of services.” That is, it is easier to find a way to pay for care that is available than to make the care available when it doesn’t exist.

And, when patients in both countries are asked to rate their satisfaction with the care they receive, the typical American, in spite of a reputation for complaining, was happier than the typical Canadian.

The NBER report conclusions basically are these:

Americans have a slightly higher incidence of chronic health problems than Canadians, but they also have higher treatment rates.

The discrepancies between income and health care received has not disappeared in Canada and is actually steeper than in the United States.

More Americans report satisfactory health care than do Canadians.

That some are recommending the Canadian system for the United States seems odd if the NBER report holds up. Even while promoting Canadian style care for the U.S., the New York Times admitted that the “country’s publicly financed health insurance system... is gradually breaking down.” It reported waiting times growing ever longer. And in light of the inability of the Canadian system to provide the care it promised the nation’s Supreme Court ruled that bans on private medical care were unconstitutional and inhumane.

Once the court opened the way for private care Canadians were flocking to the new private alternatives. Even in Quebec, a hotbed of support for socialized care, the premier has announced that the state system will be sending patients to private care facilities for treatment that the state is incapable of providing. In spite of a severe doctors shortage in the country Quebec is still forbidding physicians who provide private care from working in the state system, yet in spite of that regulation, the province has more private clinics than any other province. The Times reported new private clinics opening in Canada at the rate of one per week.

The recently elected head of the Canadian Medical Association, Dr. Brian Day, actually runs one of the largest private hospitals in Canada. And, he is planning to open several more. But what started in 1996 with 30 doctors now has 120 physicians on staff. And the provincial state care system has sent them over 1,000 patients for operations that they simply couldn’t do in a timely way.

The Times reports that nationalized health care in Canada has long been “sacrosanct” and “even central to the national identity.” The explosion of private health services there marks a dramatic shift. Antonia Maioni, of McGill University says that there has “been a change in what is feasible and what is permissible in public debates” regarding nationalize health care in Canada. “Five years ago someone like Brian Day would never have been elected president of the Canadian Medical Association. Five or 10 years ago there was much more a consensus about the sustainability of the public system.” Apparently the confidence in that system is waining based on the experiences it is providing.

Wait and Die. The nationalized health alternative.

A short film, about 8 minutes, discussing how Canada rations health care and the results of that policy.



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Sick and Sicker

Michael Moore fictionalizes socialized health care.

Michael Moore produces some of the most popular fictional films around today. Unfortunately he pretends they are based on reality. He prefers that everyone else pretend they are based on reality as well.

Recently he got a bit miffed because Canadian journalists were less than laudatory in discussing his new attack on America's quasi-private health care. Moore’s film promotes Canada, along with communist Cuba, as being his role model for health care. He simply overlooks the massive problems with Cuban health care.

The Canadian journalists knew his hype about the wonders of Canada’s system was a distortion of the facts. One journalist explained: “We Canucks were taking issue with the large liberties Sicko takes with the facts, with its lavish praise for Canada’s government-funded medicare system compared with America’s for-profit alternative.”

Moore implied that Canada provides all the health care people need or want. That is false. Every country, without exception, has to restrict access to health care. Advocates of state care brag that their care costs less than America's semi-private system. But they don’t admit that this is done by simply denying health care in one form or another.

Most countries, Canada included, reduce the demand for health care by forcing people to wait for care. Often people wait right up until they die. When they do die they are taking off the waiting list and politicians call that an improvement.

These systems forbid certain treatments or medicines outright because they cost too much, even when they are precisely what the patient needs and even if the cheaper alternatives don't work as well. Some countries, like Germany, also pay very low wages to the health care professionals. In a sense they move their expenses off the books. Instead of paying market wages to doctors and increasing taxes they reduce the wages of physicians. They indirectly impose high taxes on doctors. Thus they can pretend the health care is “cheaper” than it is in reality.

The New York Times mentioned how Canada’s health care system was a major election issue there. Why was that the case? If the system is as wonderful as Moore pretends what was the problem? According to the Times it was because of growing “waiting lines for care” and because “doctors and nurses [were] becoming sparse.” Every year or so the Canadian politicians make large promises how they will reduce the waiting lines for care. But the lines don't get shorter.

It is important to remember that Canadian health care costs are also kept artificially low because Canadians are forbidden by law to have private health care. One survey of just three American states found an average of around 1,000 Canadians per year seeking treatment, at their own expense in US facilities. Their spending is then listed as US spending and not as Canadian expenditures.

This was a study, that while claiming it was impartial, was constantly worded in a way which tried to down play the problems in Canada. They also cited a survey which showed “only 20” out of 18,000 Canadians sought care in the US. If that is the case that would be about 2,000 per year. This would be equivalent of 20,000 Ameicans per year running to Canada for their operations -- if that happened you can be assured it would widely publicized and Moore would feature it heavily in his film.

Why are 2,000 people a year seeking health care in the US when it’s “free” at home? Remember private health care in Canada is illegal. While it is not a crime to seek that care outside Canada how many people understand the distinction? Would people be reluctant to admit they sought care in the US due to fears, unfounded as they would be, about breaking the law? And this survey only shows how many actually went through the bother of traveling outside their own country to seek health care. It doesn’t show how many would have done so had they the means to do it.

What I run into from apologists for socialized service is that the reason for these problems is a shortage of funding. Now think about that for a second. They are saying that if they spent more money then state care wouldn’t have to be rationed out. And no doubt some of the problems would be solved by spending considerably more.

But so often they start out with an argument that socialized service is preferred because it is cheaper. Then they excuse the problems created by socialized medicine by saying these problems wouldn’t exist if it were more expensive. Doesn’t that undermine their original claim?

Assume they doubled the budget of health care thus making socialized care far more expensive than private care. Would that eradicate the waiting lines? It would not. Demand would continue to expand. People would still want more than they received and they would seek that extra treatment. Once again they would be rationing care. One reality of economics is that if something is free, and valuable, people will want more than exists. One way or another there is always rationing.

The problems of health care rationing and the ban on private care went all the way to the Supreme Court of Canada. In Quebec the province allowed private insurance only for procedures not covered by the socialized system. One elderly man, George Zeliotis, needed a hip replacement. But the socialized system had him wait for over a year. He wanted private treatment which he would pay for out of his own pocket and was told it was illegal. He went to court and the Supreme Court wrote a blistering ruling. They ruled:

“The evidence in this case shows that delays in the public health care system are widespread and that is some serious cases, patients die as a result of waiting lists for public health care.”

“In sum, the prohibition on obtaining private health insurance is not constitutional where the public system fails to deliver reasonable services.”

No wonder Canadian journalists were a bit testy with Mr. Moore and his praise for socialized health care. I’m sure Moore will have an explanation on why he is a better judge on the matter than the Canadian Supreme Court. And the explanation would be about as fictional as most his other work.

Socialized medicine in practice