Opinion by Nurse Mark
I’m not sure just how many other of our readers had strong feelings about the opinion article that I wrote for our last HealthBeat Newsletter titled "Some Thoughts On Universal Health Care" but at least one reader was somewhat unhappy with my thoughts on the subject.
Linda has been a patient and Wellness Club member for many, many years – and she wrote to say that she felt that her side of the argument should be given equal coverage.
Here is the exchange of emails between Linda and Dr. Myatt and me:
Linda responded to my opinion article with this email:
Dear Mark
I must take issue with many points you and the WSJ author made about Canadian healthcare. I agree wholeheartedly with "Susan" who responded to the Journal. Unfortunately I was not able to respond directly as it would not accept my e-mail address!
The obvious answer as to why Americans want a new healthcare system is that the system we now have is much too expensive. Remember also that money is saved not only by patients waiting but also by not duplicating expensive medical equipment unnecessarily! On the other side of the coin remember that Canadians have a lower neo-natal death rate than the US because ALL pregnant women receive prenatal care!
I have had much first hand experience with the Canadian system (in Ontario) and have no complaints nor does my family living near Toronto. My sister in law recently experienced pancreatitis of unknown origin and she was treated as rapidly as she would have been here……….even over Christmas!! My experience with my mother’s terminal illness was just as positive with everything we needed to care for her at home provided for free.
I am surprised, Mark, that you could not provide a less biased opinion. People like you will prevent change from ever happening here!! Linda
Then Linda sent this follow-up message:
Dear Mark
This is a letter from my brother in Oakville Ontario that he sent after reading yours and the WSJ. I certainly hope you publish these so that your readers have both sides of the picture. Linda
Subject: Health care
Just read the article such a crock–they tend to focus on I would venture to say are isolated cases and ride them to death–where do they say that our life expectancy is greater than the US ? that the US has the highest per capata cost for health care in the world.? Don’t tell me that you don’t have to wait in US emerg rooms.and to focus on wait times for surgury for hips etc is wrong–Carol was diagnosed with breast cancer had two surgeries and was finished her radiation within 6mos –Sandy has had a knee and hip replaced all within 5 mo–I could go on but basically if your sick you will get treated–enough my bp is going up!
G
Dr. Myatt and I discussed these letters, and Dr. Myatt wrote back to Linda assuring her that her views would be published:
To which Linda replied:
Thank you. I think we all have a responsibility to know both sides of the picture. Linda
Dr. Myatt wrote Linda back for some additional information – since we like to be sure that we have our facts straight – Linda’s answers are embedded in Dr. Myatt’s note in italics:
Hi Linda.
You’re right; opposing opinions should be absolutely fair game. Of course, you must know that we will respond to your opinion with our opinion of your opinion!
That’s only fair, don’t you think? Yes however I hope you will acknowledge the facts I sited.
Will you please confirm these factoids with me? I don’t want to speak out of turn.
How long have you lived in the US? Over two decades if memory serves me right. Correct
Married to a US citizen, correct? Yes since 1963.
You’re still a Canadian citizen, never naturalized to the US, correct? Yes interestingly enough I was about to get my citizenship but it costs $800. !! I figured I had better uses for the money. When I moved here dual citizenship was not permitted by the US
How was your hip surgery paid for? (US medical insurance or other?) Private insurance and large out of pocket. I was not on Medicare then!
How many years did you practice as a nurse in Canada? 2 years and don’t forget I have also practiced here.
I don’t mind one little bit posting your opinion pieces, and let’s expect we’re still friends after this dialogue. I’m trusting we can "agree to disagree." That’s one thing I love about the US, that ol’ Freedom of Speech thing that hasn’t been totally stripped away just yet!
In Health,
Dr. Myatt
So, there you have Linda’s communications to us, published here as promised.
It seems that this is a subject that is destined to be forever mired in emotion, rhetoric, and misinformation presented by diametrically opposed political philosophies. That is unfortunate since all the shouting and gesticulating by those at the extremes of this issue make it difficult to concentrate on the more legitimate concerns of each side.
Linda requested equal space so that we would “acknowledge the facts I sited.”
Try as I might, I was only able to find one “fact” in Linda’s initial letter and two in her brother’s letter. Even those facts were not referenced – I had to search for the references to be sure they were indeed a fact.
Linda asserted: “Canadians have a lower neo-natal death rate than the US because ALL pregnant women receive prenatal care!”
I was able to track this down, and it is true – according to the Public Health Agency of Canada there are only 5.6 infant deaths per 1000 live births in Canada, compared to 7.8 infant deaths per 1000 live births in the US.
But let’s be really fair here: the Public Health Agency of Canada also tells us that Canada ranks below countries such as Japan, Finland, Sweden, Switzerland, France, and Denmark – who have infant death rates as low as 3.8 per 1000 in the case of Japan. What’s more, according to these same figures New Zealand – another country boasting socialized health care that proponents often look to with envy – is listed as having an infant death rate of 7.4 per 1000 – only marginally better than that of the US, and rather poorer than that of Canada.
Linda’s Canadian brother dismisses our views as “a crock” and asserts ”our life expectancy is greater than the US” and “the US has the highest per capita cost for health care in the world”. Well, according to the Organization for Economic Co-operation and Development this is true. Canada spends 9.9 percent of its Gross Domestic Product (GDP) on healthcare or $3,165 (USD) per person, compared to the 15.3 percent or $6,102 that is spent in the US. In terms of life expectancy, Canadians can expect to live 79.9 years, compared to Americans who will live, statistically, only 77.5 years. But if spending less to get more is the name of the game here we must also consider Japan – where only 8% of GDP or $2,249 person is spent per person to achieve longevity of 82.1 years. New Zealand, spending 8.4% of GDP but only $2,083 per person sees it’s people living nearly as long as Canadians – 79.2 years.
Perhaps this is all not quite as cut-and-dried as some would have us believe?
As Wikipedia says: “Researchers caution against inferring health care quality from some health statistics. June O’Neill and Dave O’Neill point out that "…life expectancy and infant mortality are both poor measures of the efficacy of a health care system because they are influenced by many factors that are unrelated to the quality and accessibility of medical care"”
Linda tells us with obvious pride that her sister received treatment in Canada “as rapidly as she would have been seen here” for an urgent pancreatitis. That is as it should be, for pancreatitis is considered a medical emergency no matter what country you are in, and treatment must be – and is – immediate no matter whose medical system is doing the treating. Linda tells us that her mother was cared for at home through her terminal illness, “with everything we needed to care for her at home provided for free” – as it might have been in the US under Medicare since her mother was presumably a senior.
Her brother cites examples of a breast cancer patient who was diagnosed, cut upon, irradiated and presumably declared ‘done’ all within 6 months, and someone who had both a hip and knee replaced within 5 months.
I will let these numbers speak for themselves – they do not seem particularly speedy treatment times to me, and we do not know enough about either example to know the urgency of the case. In either country emergencies are treated immediately, urgent cases come next, and the less urgent may wait longer. I will add that my own mother, living in Canada, has been suffering for several years with hip pain and begging for hip replacement surgery for well over a year, to no avail. She is quickly becoming weak and debilitated and losing her ability to walk but it seems her case is not considered “urgent” enough by the Canadian system and so she is required to wait.
It is worth noting that in the US we would have the option of going outside of the Medicare system for mom, and finding a surgeon and a hospital to give her the new hip she needs by the simple expedient of paying for it. That is illegal in Canada – for it is considered “jumping the queue” and to allow people to do so would lead to the creation of a “Two-tier” medical system – an anathema to Canada’s more left-leaning or socialist political parties who derisively contend that this would result in the “rich” being able to buy faster care than the “poor”. Personally I have always considered that to be a weak argument – for it is my opinion that allowing someone who can afford to do so the opportunity to buy faster care would effectively open up their place in the line, letting someone else be seen sooner – somewhat the way the VIP desk at the airport check-in counter takes some of the load off the line of “regular-folk” in coach-class and lets them move that much faster.
In my twenty years of Canadian experience as a practicing Nurse, surgeons are limited by the operating hours set by the hospital – which are dictated by the budget allotted to them by the government. When the OR is closed, no matter how much the surgeon wants to he cannot perform an elective surgery – the hospital will not provide the staff or the ancillary services. In the US, that surgery can be done as long as the patient is willing to pay – the hospital will be more than happy to take the money!
I must also comment on this statement from Linda’s initial email to me: “Remember also that money is saved not only by patients waiting but also by not duplicating expensive medical equipment unnecessarily!”
Linda, I truly hope that you miss-spoke with this sentence, and that you meant to phrase this differently – for the idea of saving money by making patients wait for medical care is repugnant to me and it bespeaks what I consider to be the evil of the rationing of health care that seems to inevitably creep into government enforced tax-funded plans. Whether it is Canada’s or Britain’s or New Zealand’s publicly-funded schemes or America’s own Medicare, Medicaid, V.A., or State Children’s Health Insurance Programs, demand always seems to outstrip the ability of the government to pay leaving legislators scrambling for more money and bureaucrats struggling with fixed and inadequate budgets.
No, making patients wait is NOT an ethical way to save money, and I reject that strategy.
As to the duplication of expensive medical equipment, if doctors and patients are demanding equipment, and are willing to pay for it, why shouldn’t they be entitled to it? Are the people of a town any less deserving of a CT scanner than the people of the city 50 miles away? If the people want it and are willing to support it, should they not have it?
I recall the story told to me by our federal Member of Parliament (similar to a US senator) when I lived in Canada. It seems that the only MRI imaging machine in the province of British Columbia was located in Vancouver – a huge distance from most of the rest of the province. The government refused to allow another, more centrally-located MRI machine, citing the expense. Further, because of budgetary constraints, the machine was staffed only a few hours a day, and on weekdays only, severely limiting the numbers of patients who could be booked for imaging and diagnostics. Because of Canada’s laws prohibiting “private pay” for service, no patient could be seen during the times when the machine was not being operated under government funding. It should have been sitting, dark and idle, for all the time it was unfunded, but it did not. In an effort to bolster its meager budget the MRI clinic had found a solution: during the times that human patients could not be seen because of the rationing of funds, the clinic did a roaring trade (no pun intended) doing veterinary imaging. That’s right, a human was prohibited from buying service, but an animal could be seen simply by its owner plunking down cold hard cash! Since veterinary medicine is not covered by any government program in Canada, this was perfectly legal.
No, rationing medical equipment, no matter how expensive, is NOT the way to save money, and I reject that strategy too.
Linda, I fully agree that health care is expensive in the US – but I believe it is miss-named. We do not practice “health care”, we practice disease management. We do not promote health, we wait until years of soda pop, trans fats, smoking, obesity, physical inactivity and other “lifestyle choices” render us ill, then we demand that “everything possible” be done, no matter how expensive or futile. When the expensive and futile treatments fail to work, or if the doctor fails to perform some test or offer some treatment we call our lawyers to launch a lawsuit.
Certainly, many procedures and tests are ordered by doctors more concerned with avoiding lawsuits than with whether the test is necessary and will provide meaningful information that simpler, less high-tech methods like good ol’ physical examination might provide. But that does not mean that many laypeople aren’t guilty of overkill in this regard, demanding that all possible tests be run, all possible treatments be tried, and no stone left unturned by their doctor.
Defensive medical practice is a fact of life in the US, and there is no doubt that this raises costs. Malpractice payouts tend to be smaller in the US than in Canada or Britain, but more lawsuits are filed – 350% more lawsuits per person according to testimony. The costs for doctors to insure and defend themselves against this must be astronomical in terms of cash and emotional energy – can there be any surprise that a doctor’s fees are so high?
Certainly the cost of the bureaucracy involved with the medical insurance industry is out of control. Something must be done to reduce this burden for doctors and patients – but I do not believe that introducing yet another bureaucracy in the form of a new government agency is the answer. Let’s remember, this is the government that has given us such paragons of efficiency and user-friendliness as the IRS, the DOT, the FDA, OSHA, FEMA and others.
There is no doubt that there are many Americans who do not have health insurance, or to call it what it truly is, disease insurance. There are many reasons for this, and the actual figures are the subject of considerable debate. Census figures estimate that just over 59 % of Americans have disease insurance through their employers, nearly 28% have government-provided coverage, around 9% purchase coverage privately, and 15% were uninsured in 2007. There is no way to know how many of that 15% are uninsured by choice (i.e.: “self-insured” – as Dr. Myatt and I are).
That brings me to another item that causes me some distress – the suggestion that health insurance must be made mandatory. The idea that I must be forced to buy insurance in order to help to underwrite the cost of insurance for others upsets me: I do everything possible to maintain my health and fitness. I find it repugnant that I would be required to help to pay to treat the diseases that are caused by the “lifestyle choices” of others. The lung cancer that comes from a lifetime of smoking, the quadruple bypass that is needed to correct the effects of years of sloth and junk food, the GERD that has resulted from stress and a miserable diet, the diabetes or obesity that is the result of simple overeating – these are preventable, so why should I be asked to subsidize them?
If someone suggested that we all buy some form of simple, limited, catastrophic disease and accident insurance I might be more amenable – but I seriously doubt that any government scheme, even if it were begun to cover only catastrophic illness or injury, would remain simple for long – for wherever a politician is involved…
Well, there you have some of my thoughts on the matter – in closing, Linda said to me:
I am surprised, Mark, that you could not provide a less biased opinion. People like you will prevent change from ever happening here!!
Here is my reply to that comment: As a newly-Naturalized citizen of the United States (I took my oath of American citizenship on Friday, June the 19th – see our HealthBeat announcement) I look forward to legitimately participating in the democratic process of this country to help bring about real, positive change.
References and additional reading:
The basics – a look at the 4 basic forms of health care systems in use around:
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/countries/models.html
And a brief discussion of the systems in place in a number of countries:
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/themes/socialized.html
Anderson GF, Hussey PS, Frogner BK, Waters HR (2005). "Health spending in the United States and the rest of the industrialized world". Health affairs (Project Hope) 24 (4): 903–14. doi:10.1377/hlthaff.24.4.903. PMID 16136632
A look at healthcare wait times in Canada by The Fraser Institute:
http://www.fraserinstitute.org/commerce.web/product_files/WaitingYourTurn2008.pdf
A look at healthcare wait times in The US by Merritt Hawkins and Associates
http://www.merritthawkins.com/pdf/mha2009waittimesurvey.pdf
An interesting article by the National Center for Policy Analysis (NCPA) titles “10 Surprising Facts about American Health Care” http://www.ncpa.org/pub/ba649#_edn6
A reasonably balanced look at the pro’s and the con’s of the concept of the government providing free universal health care to all Americans:
http://www.balancedpolitics.org/universal_health_care.htm
The full text of Mr. Obama’s speech to the American Medical Association:
http://www.forbes.com/2009/06/15/obama-health-care-business-washington-speech.html
A Wikipedia discussion of life expectancy: http://en.wikipedia.org/wiki/Life_expectancy
Some testimony regarding malpractice costs in the US: Testimony of Mark McClellan, MD, Ph.D., Administrator, Centers for Medicare & Medicaid Services, before the Joint Economic Committee Hearing on Malpractice Liability Reform, April 28, 2005
Health cost, expenditure, and life expectancy figures for OECD countries: "OECD in Figures 2006-2007" (PDF). Organisation for Economic Co-operation and Development. http://www.oecdobserver.org/news/get_file.php3/id/25/file/OECDInFigures2006-2007.pdf. Retrieved on 2007-06-21.
A comparison by Wikipedia of the American and Canadian systems: http://en.wikipedia.org/wiki/Canadian_and_American_health_care_systems_compared
The Public Health Agency of Canada discusses infant mortality improvements in that country – with statistics comparing neonatal mortality to other countries:
http://www.phac-aspc.gc.ca/publicat/meas-haut/mu_c_e.html
The US government Centers for Medicare and Medicaid Services – for a look at what the US government currently provides for socialized health care services: http://www.cms.hhs.gov/