[mike777]

VANCOUVER, British Columbia, Feb. 23 — The Cambie Surgery Center, Canada's most prominent private hospital, may be considered a rogue enterprise.

Accepting money from patients for operations they would otherwise receive free of charge in a public hospital is technically prohibited in this country, even in cases where patients would wait months or even years in discomfort before receiving treatment.

But no one is about to arrest Dr. Brian Day, who is president and medical director of the center, or any of the 120 doctors who work there. Public hospitals are sending him growing numbers of patients they are too busy to treat, and his center is advertising that patients do not have to wait to replace their aching knees.

The country's publicly financed health insurance system — frequently described as the third rail of its political system and a core value of its national identity — is gradually breaking down. Private clinics are opening around the country by an estimated one a week, and private insurance companies are about to find a gold mine.

http://www.nytimes.com/2006/02/26/internat...s/26canada.html



While proponents of private clinics say they will shorten waiting lists and quicken service at public institutions, critics warn that they will drain the public system of doctors and nurses. Canada has a national doctor shortage already, with 1.4 million people in the province of Ontario alone without the services of a family doctor.

"If anesthetists go to work in a private clinic," Manitoba's health minister, Tim Sale, argued recently, "the work that they were doing in the public sector is spread among fewer and fewer people."

[mike777]

"Let me start by pointing out something serious health economists have known all along: on general principles, universal health insurance should be eminently affordable."

---------


"Canada has a national doctor shortage already, with 1.4 million people in the province of Ontario alone without the services of a family doctor."

------


"I know plenty of imigrants who have graduated medical schools in their home countries and are trying to become a doctor in Canada, it seems there are lots of exams and very few positions available "

[luke warm]

mike777, on Jul 6 2009, 02:00 PM, said:

The country's publicly financed health insurance system — frequently described as the third rail of its political system and a core value of its national identity — is gradually breaking down. Private clinics are opening around the country by an estimated one a week, and private insurance companies are about to find a gold mine.

unless there is some federal law prohibiting (and punishing) all specialities from practicing in anything other than a public practice/clinic/hospital, it seems to me the system would have to break down

[jdonn]

luke warm, on Jul 6 2009, 02:53 PM, said:

mike777, on Jul 6 2009, 02:00 PM, said:

The country's publicly financed health insurance system — frequently described as the third rail of its political system and a core value of its national identity — is gradually breaking down. Private clinics are opening around the country by an estimated one a week, and private insurance companies are about to find a gold mine.

unless there is some federal law prohibiting (and punishing) all specialities from practicing in anything other than a public practice/clinic/hospital, it seems to me the system would have to break down

Taking everyone at their word for what is happening, it sounds to me like a very good thing to have a combination of private and public insurance options. This will give people whatever healthcare they are willing to pay for, while making sure that something is available for everyone. I would also imagine it would shorten these huge waiting periods for people using the public option.

I disagree that it would suck too many doctors from the public insurers. It would equally suck away patients, and there being more overall opportunities for people to be doctors would surely lead to more people being doctors anyway.

[luke warm]

jdonn, on Jul 6 2009, 02:55 PM, said:

Taking everyone at their word for what is happening, it sounds to me like a very good thing to have a combination of private and public insurance options. This will give people whatever healthcare they are willing to pay for, while making sure that something is available for everyone. I would also imagine it would shorten these huge waiting periods for people using the public option.

that's fine... the rich will have better health care than the poor but that's the case now, anyway

Quote

I disagree that it would suck too many doctors from the public insurers. It would equally suck away patients, and there being more overall opportunities for people to be doctors would surely lead to more people being doctors anyway.

maybe so, all we can go by are the countries that have experience with this

[Lobowolf]

jdonn, on Jul 6 2009, 02:55 PM, said:

there being more overall opportunities for people to be doctors would surely lead to more people being doctors anyway.

Depending on whether the change makes being a doctor significantly less attractive. If there are a more opportunities, but the jobs pay a lot less, then more people might choose to be things other than doctors (or choose to be doctors in other places).

I wonder if there are parallels to be drawn from the legal profession, where, at least for criminal law, everyone gets a lawyer. You can get a private lawyer, if you want to pay for one, but the government will provide a public one. There are some significant differences (you can go your whole life and not need a criminal lawyer; there hasn't been a huge changeover from an all-private system in recent history), but maybe there are enough similarities to shine some light.

[luke warm]

Lobowolf, on Jul 6 2009, 03:17 PM, said:

jdonn, on Jul 6 2009, 02:55 PM, said:

there being more overall opportunities for people to be doctors would surely lead to more people being doctors anyway.

Depending on whether the change makes being a doctor significantly less attractive. If there are a more opportunities, but the jobs pay a lot less, then more people might choose to be things other than doctors (or choose to be doctors in other places).

I wonder if there are parallels to be drawn from the legal profession, where, at least for criminal law, everyone gets a lawyer. You can get a private lawyer, if you want to pay for one, but the government will provide a public one. There are some significant differences (you can go your whole life and not need a criminal lawyer; there hasn't been a huge changeover from an all-private system in recent history), but maybe there are enough similarities to shine some light.

even if there are parallels, that might be a case for gov't run health care... court ordered legal representation is every bit as good as private, ask anyone

[Lobowolf]

luke warm, on Jul 6 2009, 03:34 PM, said:

even if there are parallels, that might be a case for gov't run health care... court ordered legal representation is every bit as good as private, ask anyone

It might be support for the idea even if it wasn't "every bit as good." The notion is to make sure that everyone gets a decent level of care. I went to a highly regarded law school, and more than a few of the people I went to school with became public defenders, including some good students and the winner of my year's Moot Court competition. These are people who turned down $150K a year straight out of school to do something they believed in. It may be the case that the same thing would happen with medical students.

[jdonn]

luke warm, on Jul 6 2009, 03:10 PM, said:

Quote

I disagree that it would suck too many doctors from the public insurers. It would equally suck away patients, and there being more overall opportunities for people to be doctors would surely lead to more people being doctors anyway.

maybe so, all we can go by are the countries that have experience with this

I don't anticipate America doing that since we seem to be doing quite a bad job learning from our own experience.

[helene_t]

jdonn, on Jul 6 2009, 08:55 PM, said:

Taking everyone at their word for what is happening, it sounds to me like a very good thing to have a combination of private and public insurance options.

Yes but the Canadian situation sounds terrible (as it has been described here). People who opt for a private clinic because they can't tolerate the waiting lists pay twice: via the taxes for the public health services they don't get, and directly for the private ones they do get. It's the same here in the UK.

In Denmark they used to have (still have? I haven't followed it for a decade) a system of guaranteed waiting times. If the municipalities exceed those times, people could(can?) opt for a private/abroad solution and send the bill to the municipality.

May sound cool but there is a problem: GPs have been known to refer their patients to procedures which they might need in the future, so that if/when they need the procedure they will already have served most of the waiting time.

I have heard hospital physicians argue that waiting lists are good for the economy, not only because they eliminate the costs associated with idle capacity, but also because a substantial part of the patients (more than 50% in some specialisms) recover while waiting. One could speculate that most of those spontaneous recoverors wheren't sick in the first place.

There is a large non-profit organization in Denmark that offers for-pay supplemental insurance. It has a pay-out rate of 90%. So private insurance can be efficient, too. At least in terms of administrative overhead. Wrt some procedures (for example most dentistry) it works fine in that people who are insured still get the municipality coverage, and the private insurance then takes over where the public one stops. Potentially this could be a burden on the public system as the private insurance motivates people to over-use procedures which are partly payed for by the municipality - I don't know to what extends that is a problem in practice.

Wrt other procedures (for example lense transplants) it is less ideal as people can chose for 100% coverage at a public hospital or some 50% (appr.) coverage by the private insurance at a private hospital (in case the waiting list is too long or they are somehow not eligible for treatment at a public hospital). But I think that in any care financing model it would be impossible to avoid some degree of skew incentives as well as some degree of unfairness (whatever that means).

Quote

I disagree that it would suck too many doctors from the public insurers. It would equally suck away patients, and there being more overall opportunities for people to be doctors would surely lead to more people being doctors anyway.

That sounds plausible.

[y66]

Saw this story titled Plenty of countries get healthcare right by Jonathan Cohn cited on Krugman's blog

Quote

“I DON’T WANT America to begin rationing care to their citizens in the way these other countries do.”

That was Arizona Senator Jon Kyl, speaking last month about healthcare reform. But it could have been virtually any other Republican, not to mention any number of sympathetic interest groups, because that’s the party line for many who oppose healthcare reform. If President Obama and his supporters get their way, this argument goes, healthcare in America will start to look like healthcare overseas. Yes, maybe everybody will have insurance. But people will have to wait in long lines. And when they are done waiting in line, the care won’t be very good.

Typically the people making these arguments are basing their analysis on one of two countries, Canada and England, where such descriptions hold at least some truth. Although the people in both countries receive pretty good healthcare - their citizens do better than Americans in many important respects - they are also subjected to longer waits for specialty care and tighter limits on some advanced treatments.

But no serious politician is talking about recreating either the British or the Canadian system here. The British have truly “socialized medicine,” in which the government directly employs most doctors. The Canadians have one of the world’s most centralized “single-payer” systems, in which the government insures everybody directly and private insurance has virtually no role. A better understanding for how universal healthcare might work in America would come from other countries - countries whose insurance architecture and medical cultures more closely resemble the framework we’d likely create here.

Last year, I had the opportunity to spend time researching two of these countries: France and the Netherlands. Neither country gets the attention that Canada and England do. That might be because English isn’t their language. Or it might be because they don’t fit the negative stereotypes of life in countries where government is more directly involved in medical care.

Over the course of a month, I spoke to just about everybody I could find who might know something about these healthcare systems: Elected officials, industry leaders, scholars - plus, of course, doctors and patients. And sure enough, I heard some complaints. Dutch doctors, for example, thought they had too much paperwork. French public health experts thought patients with chronic disease weren’t getting the kind of sustained, coordinated medical care that they needed.

But in the course of a few dozen lengthy interviews, not once did I encounter an interview subject who wanted to trade places with an American. And it was easy enough to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care. Physicians felt free to practice medicine the way they wanted; companies got to concentrate on their lines of business, rather than develop expertise in managing health benefits. But, in contrast with the US, everybody had insurance. The papers weren’t filled with stories of people going bankrupt or skipping medical care because they couldn’t afford to pay their bills. And they did all this while paying substantially less, overall, than we do.

The Dutch and the French organize their healthcare differently. In the Netherlands, people buy health insurance from competing private carriers; in France, people get basic insurance from nonprofit sickness funds that effectively operate as extensions of the state, then have the option to purchase supplemental insurance on their own. (It’s as if everybody is enrolled in Medicare.) But in both countries virtually all people have insurance that covers virtually all legitimate medical services. In both countries, the government is heavily involved in regulating prices and setting national budgets. And, in both countries, people pay for health insurance through a combination of private payments and what are, by American standards, substantial taxes.

You could be forgiven for assuming, as Kyl and his allies suggest, that so much government control leads to Soviet-style rationing, with people waiting in long lines and clawing their way through mind-numbing bureaucracies every time they have a sore throat. But, in general, both the Dutch and French appear to have easy access to basic medical care - easier access, in fact, than is the American norm.

In both the Netherlands and France, most people have long-standing relationships with their primary care doctors. And when they need to see these doctors, they do so without delay or hassle. In a 2008 survey of adults with chronic disease conducted by the Commonwealth Fund - a foundation which financed my own research abroad - 60 percent of Dutch patients and 42 percent of French patients could get same-day appointments. The figure in the US was just 26 percent.

The contrast with after-hours care is even more striking. If you live in either Amsterdam or Paris, and get sick after your family physician has gone home, a phone call will typically get you an immediate medical consultation - or even, if necessary, a house call. And if you need the sort of attention available only at a formal medical facility, you can get that, too - without the long waits typical in US emergency rooms.

This is particularly true in the Netherlands, thanks to a nationwide network of urgent care centers the government and medical societies have put in place. Not only do these centers provide easily accessible care for people who use them; they leave hospital emergency rooms free to concentrate on the truly serious cases. Tellingly, a Dutch physician I met complained to me that waiting times in her emergency room had been getting “too long” lately. “Too long,” she went on to tell me, meant two or three hours. When I told her about documented cases of people waiting a day, or even days, for treatment in some American emergency rooms, she thought I was joking. (In a 2007 Commonwealth Fund survey, just 9 percent of Dutch patients reported waiting more than two hours for care in an ER, compared to 31 percent of Americans.)

Dutch and French patients do wait longer than Americans for specialty care; around a quarter of respondents to the Commonwealth Fund survey reported waiting more than two months to see a specialist, compared to virtually no Americans. But Dutch and French patients were far less likely to avoid seeing a specialist altogether - or forgoing other sorts of medical care - because they couldn’t afford it. And there’s precious little evidence that the waits for specialty care led to less effective care.

On the contrary, the data suggests that while American healthcare is particularly good at treating some diseases, it’s not as good at treating others. (In some studies, the US did pretty well on cardiovascular care, not so well on diabetes, for example.) Overall, the US actually fares poorly on measures like “potential years of lives lost” - statistics compiled by specialists in an effort to measure how well healthcare systems perform. In a 2003 ranking of 20 advanced countries, the US finished 16th when it came to “mortality amenable to healthcare,” another statistic that strives to capture the impact of a health system. The Dutch were 11th and the French were fifth. These statistics are necessarily crude; diet, culture, and many other factors inevitably affect the results. But, taken together, they make it awfully hard to argue that care in these countries is somehow inferior. If anything, the opposite would seem to be true.

Critics of health reform frequently point to cancer as proof that American healthcare really is superior. And, it’s true, the US has, overall, the world’s highest five-year survival rate for cancer. But that’s partly a product of the unparalleled amount of government-funded research in the US - something healthcare reform would not diminish. Besides, it’s not as if the gap is as large or meaningful as reform critics frequently suggest. France (like a few other European countries) has survival rates that are generally close and, for some cancers, higher. Much of the remaining difference reflects differences in treatment patterns that have nothing to do with insurance arrangements and everything to do with idiosyncratic medical cultures. This is particularly true of prostate cancer, where a staggeringly high survival rate in the US seems to be largely a product of aggressive US treatment - treatment that physicians in other countries, and increasingly many specialists here, consider unnecessary and sometimes harmful.

None of this is to say that either the Dutch or French systems are perfect. Far from it. In both countries, healthcare costs are rising faster than either the public - or the country’s business interests - would like. And each country has undertaken reforms in an effort to address these problems. The French have started to introduce some of the managed care techniques familiar to Americans, like charging patients extra if they see specialists without a referral, while developing more evidence-based treatment guidelines in the hope that it will reduce the use of unnecessary but expensive treatments. The Dutch overhauled their insurance arrangements a few years ago, to introduce more market competition and reward healthcare providers - that is, doctors and hospitals - who get good results.

But cost is the one area in which France and the Netherlands are a lot like Canada and England: They all devote significantly less of their economy to healthcare than we do. The French spend around 11 percent of their gross domestic product on healthcare, the Dutch around 10. In the US, we spend around 16 percent. And, unlike in the US, the burden for paying this is distributed across society - to both individuals and businesses - in an even, predictable way.

Of course, reforming health insurance in the US isn’t going to turn this country into France or the Netherlands overnight, any more than it would turn the US into Britain and Canada. The truth is that the changes now under consideration in Washington are relatively modest, by international standards. But insofar as countries abroad give us an idea of what could happen, eventually, if we change our health insurance arrangements, the experience of people in Amsterdam and Paris surely matters as much as - if not more than - those in Montreal and London. In those countries, government intervention has created a health system in which people seem to have the best of all worlds: convenience, quality, and affordability. There’s no reason to think the same thing couldn’t happen here.

Jonathan Cohn is a senior editor of The New Republic, where he writes a blog called “The Treatment.” He is also the author of “Sick: The Untold Story of America’s Health Care Crisis - and the People Who Pay the Price (HarperCollins, 2007). 

[luke warm]

a way to pay for it

this is talking about the various cafeteria plans that allow people to pay their healthcare premiums pretax, lowering their taxable income... what i didn't see mentioned (i may have missed it), but which you can bet will be talked about, are the other "flexible benefits" programs, such as the one that allows employees to withhold up to $6,000 per year pretax to be used for things either covered or not covered by their health insurance... also, there is a dependent care option that allows employees to withhold an amount determined by how income tax is filed (up to, i believe, $5,000)... this is also withheld pretax

this could be a very big thing and might increase the fighting

[PassedOut]

luke warm, on Jul 7 2009, 01:17 PM, said:

a way to pay for it

this is talking about the various cafeteria plans that allow people to pay their healthcare premiums pretax, lowering their taxable income... what i didn't see mentioned (i may have missed it), but which you can bet will be talked about, are the other "flexible benefits" programs, such as the one that allows employees to withhold up to $6,000 per year pretax to be used for things either covered or not covered by their health insurance... also, there is a dependent care option that allows employees to withhold an amount determined by how income tax is filed (up to, i believe, $5,000)... this is also withheld pretax

this could be a very big thing and might increase the fighting

Yes, I expect that all these programs will be looked at and some changes made.

We're quite interested here in how that will play out, because one of our companies now provides 100% paid health insurance plus a medical reimbursment plan that covers basically everything not paid for by the insurance policy, including co-pays. To the extent that those benefits become taxable, we'll take a hit.

I hope the new taxes will be offset, at least partly, by lower medical costs. But things cannot go on as they are. We'll be able to adapt to whatever the government comes up with.

[luke warm]

PassedOut, on Jul 7 2009, 02:03 PM, said:

I hope the new taxes will be offset, at least partly, by lower medical costs. But things cannot go on as they are. We'll be able to adapt to whatever the government comes up with.

that will only be the case if there's a medicare-like fee schedule and if providers are prohibited from balance billing

[onoway]

One of the problems with health care in Canada is the dedication of a number of politicians for whatever reason, to bring American style health care and allow for profit clinics and such in. This was originally not allowed and indeed was once scuttled by the government threatening to withhold federal monies from Alberta when it was first tried.

However, the power of the federal government has been eroded and the singleminded dedication of people like ex premiere Ralph Klein has not only punched a hole in the wall, he has put flares around the gap to show the way. He pulled down a number of hospitals (two major ones in Edmonton alone) and redesignated others to lose their hospital status (one of which in Edmonton had just undergone a major remodelling and expansion) then said clinics were needed as there was a shortage of beds.(Which of course, then there were.)

The problem is that with clinics there is indeed money to be made, a great deal of it sometimes, and that will unfortunately lead to people looking to their own interests rather than the interests of the people they are being well paid to serve.If the clinics were forced to fund their practice without any compensation from the government, perhaps there would be a lot less enthusiasm on the part of these entrepeneurs. And a lot fewer patients. So they wouldn't be so profitable and doctors perhaps not so eager to leap aboard the what is now a gravy train.

When some people in both government and the medical profession are working to undermine the system, to make it cumbersome, awkward, handicapped by lack of facilities and moan constantly about costs, it's tough . It was working very well indeed until it started to get undermined by people in power with their own agendas. If doctors had to go back to the days of billing people directly and hoping to get paid, (and not with live chickens or several sacks of potatoes) as was once the case, they might tend to regard a health care system with less jaundiced eyes.

[luke warm]

onoway, on Jul 8 2009, 02:41 PM, said:

If doctors had to go back to the days of billing people directly and hoping to get paid, (and not with live chickens or several sacks of potatoes) as was once the case, they might tend to regard a health care system with less jaundiced eyes.

i could be wrong here, but aren't doctors in the group that would rather have healthcare private than public?

[Lobowolf]

onoway, on Jul 8 2009, 02:41 PM, said:

One of the problems with health care in Canada is the  dedication of a number of politicians for whatever reason, to bring American style health care and  allow for profit clinics and such in. This was originally not allowed and indeed was once scuttled by the government threatening to withhold federal monies from Alberta when it was first tried.

However, the power of the federal government has been eroded and the singleminded dedication of people like ex premiere Ralph Klein has not only punched a hole in the wall,  he has put flares around the gap to show the way. He pulled down a number of hospitals (two major ones in Edmonton alone) and  redesignated others to lose their hospital status (one of which in Edmonton had just undergone a major remodelling and expansion)  then said clinics were needed as there was a shortage of beds.(Which of course, then there were.)

The problem is that with clinics there is indeed money to  be made, a great deal of it sometimes, and that will unfortunately lead to people looking to their own interests rather than the interests of the people they are being well paid to serve.If the clinics were forced to fund their practice without any compensation from the government, perhaps there would be a lot less  enthusiasm on the part of these entrepeneurs. And a lot fewer patients. So they wouldn't be so profitable and doctors perhaps not so eager to leap aboard the what is now a gravy train.

When some  people in both government and the medical profession are working to undermine the  system, to make it cumbersome, awkward,  handicapped by lack of facilities and moan constantly about costs,  it's tough . It was working very well indeed until  it started to get undermined by people in power with their own agendas. If doctors had to go back to the days of billing people directly and hoping to get paid, (and not with live chickens or several sacks of potatoes) as was once the case, they might tend to regard a health care system with less jaundiced eyes.

This sounds like the wrong end of a chicken and egg question. If private clinics are so incredibly profitable, perhaps that suggests that the all-public system wasn't so great after all.

If you pass a law that nobody's allowed to sell steak, you could probably convince people that the government-provided hamburger is the best thing they could possibly have. (Godawful analogy for a vegan, I know). "Everything was awesome, until there were alternatives."

[luke warm]

how do you feel about mandatory insurance?

[PassedOut]

luke warm, on Jul 8 2009, 04:55 PM, said:

how do you feel about mandatory insurance?

Good.

[jdonn]

Almost mandatory. People with very low incomes (I think something in the $16,000 a year neighborhood) would not be required. Anyway I think it's good as long as there is some program such as subsidies to make it relatively affordable for everyone. Obviously it would be bad to fine people for not buying something they can't possibly afford. Then what do you do if they can't pay the fine either, throw them in jail for being too poor? At least with mandatory car insurance you have the possibility of not owning a car. No such option exists with mandatory health insurance, other than dying.