So I disappeared for a full week, right in the middle of what should have been a busy writing schedule, and I have to claim some “personal days” to cover the time we missed here at the blog – but it won’t be time entirely wasted.
Instead, I’m going to jump into my own personal life for today’s story, and I’m going to do it so that we can stimulate some thinking about where we really need to go to if we ever hope to make some sense out of the crazy way we deliver health care in this country.
Since this appears to be the weekend that a lot of decisions are either going to be made about the future of our “social safety net”…or they wont; we’re entirely unsure…let’s talk about how it actually works for a lot of us – and how it could work a lot better.
But the worst part of the Industrial Revolution – and the part that has never been documented – is what happened to the role of managers. The owners of factories realized they needed a layer of insulation between themselves and the people they were exploiting. They needed the type of people who were incapable of understanding the workers’ pleas for common sense, decency, and safe working conditions. The owners wisely chose managers for these roles.
–Scott Adams, from the book “Dogbert’s Top Secret Management Handbook”
So as most of you know, I am a blogger, and that means, for better or worse, that this is how I’m trying to make a living – and as a result I, along with about 50,000,000 other Americans, find myself on the DGS Health Plan (never heard of DGS? It’s the “Don’t Get Sick” Health Plan).
So what do I do? The same as a lot of you: I don’t get sick.
And up ‘til now, it’s worked out surprisingly well, even though I weigh more than I should and I have a coke addiction that can see me consuming as much as 2 liters in a single day…but by last Friday I had one of those tooth twinges building up that you know is not going to end up well.
By Friday night things were getting bad enough that I had to tell The Girlfriend that we were very likely to be going to an Emergency Room, if not that night, certainly by morning – unless things cleared up on their own, which, if you’re an optimist, could happen.
So much for optimism.
Midday Saturday we’re in downtown Seattle and I’m waiting in line to be seen by an intake clerk, then a triage nurse, and then a financial counselor, because there’s no way I can really take on a big medical bill.
I’m lucky that Washington State has a “Charity Care Law”; that law requires Washington’s hospitals to accept all comers at the Emergency Room, regardless of ability to pay – and there’s been a considerable increase in demand over the past four years.
(The Department of Health reports that $591 million in such care was provided in ’07, and in the last year for which numbers are available, ’09, the same cost had run up to $846 million; that’s a 43% jump in just two years. The odds are pretty good that the ’10 and ’11 numbers will also show an increase that’s well above the rate of inflation.)
Anyway, after that they showed me to a sort of mini-Emergency Room facility, I was examined by a Medical Student and his Instructor, and they decided that maybe a CAT scan would be a good idea, just to determine exactly how badly and how widespread this infection might be.
I rode the ride, an assessment was made, and it time to offer up my various elbows to my Medical Student, which left me with a couple of bruises that are still healing, and him with a couple of experience points.
More assessment followed the return of the lab results; as a result I was given a prescription of a rather unpleasant antibiotic that I’ll be taking for a few more days, but all in all, for me, things worked out pretty well.
That said…imagine if I lived in Canada.
First thing, I waited longer than I should have with this infection, and if I had a General Practitioner with whom I had an ongoing relationship, I would have gone there at least a day sooner.
That delay imposed a few costs: I had that CAT scan, took up ER time and a mini-ER suite; instead I could have made an office visit, and probably walked out with a prescription for the same antibiotic with a quick exam or just a blood test.
There is no financial counselor in Canadian healthcare – instead, you present your Provincial insurance card, and that’s that. For those not aware, Canadian healthcare, for the most part, works like American care, except there’s only one insurance company, and that’s each Province; they also collect taxes to fund the services.
That means providers only deal with one insurer, and all of that cuts a lot of administrative expenses out of the system. It also means patients never have to worry about whether their provider will be “in the network”.
(Fun Fact: bankruptcy is now a big part of the American medical system. In 1981 8% of bankruptcies were related to medical costs, but by 2007 that number appears to have grown to 62%, all this according to the Journal of the American Medical Association. Three-quarters of that 62% had medical insurance.
Canada does not have a medical bankruptcy problem of statistical significance.)
When you add all this together, it begins to explain how it’s possible that Canada can insure all their people for about 11% of their 2009 Gross Domestic Product (GDP) when we pay about 17% of GDP and still leave a huge portion of the population either completely uninsured or unable to pay for care even if they have insurance, due to what won’t be covered when the bill comes in at the end of the month.
(Fun Fact #2: Sweden, Switzerland, France, Germany, Iceland – in fact, any country that you can name on the face of the Earth – pays less than we do for their health care.
When it comes to the cost of health care, the USA is #1.)
So it’s not all skittles and beer, up there in Canada. You might have to wait a while to get some types of care, and it appears that there’s an element of “rationing by waiting period”, which is a constant source of complaints up there. (The counterargument is that rationing of some sort is required in any medical insurance scheme; otherwise, you’ll have folks at the doctor’s for no reason at all, and that’ll quickly drive a system broke.)
There are co-pays, for some services, and no coverage for others, depending on your Province, (nonemergency dental and vision are often not covered) and that can lead to some out-of-pocket, but for the most part taxes cover the bills.
And just as we in the USA are struggling to pay for medical care, so is everyone else: controlling medical costs are hard, for a variety of reasons, including the cost of paying medical professionals to do work in a dangerous environment that can often be hard to automate.
Dangerous, you say?
In healthcare, back injuries, frequently caused by overexertion, occur at a very high rate. Healthcare industry workers sustain 4.5 times more overexertion injuries than any other type of worker…According to national statistics, six of the top 10 professions at greatest risk for back injury are: nurse’s aides, licensed practical nurses, registered nurses, health aides, radiology technicians, and physical therapists.
So the other reason I’m having this conversation today is because I was having a talk with a very nice gentleman just about 48 hours ago who is a bit more Conservative politically than I, and he wondered how I felt about “Obamacare” (formally known as the Affordable Health Care Act).
I’m not a big fan of that plan, I’m not, and that’s because I’d much rather do something like expand Medicare to everyone, or “go all Canada”; either choice seems simpler and easier and doable at far lower administrative costs than any plan that relies on private insurers, as the Affordable Health Care Act does.
So there you go: that’s how I spent the weekend, and a couple of days after to boot, and if we were living in Canada I could have had the same problem, but it would have cost the healthcare system a whole lot less money – and when everyone gathered at the White House today, I wish that’s what they had been talking about.
…but you multiply this by a few million, year after year, and you can see what “bending the cost curve” actually means.
Good point, except that outpatient drugs are not covered by the Canadian System. See http://www.drugcoverage.ca/p_reimburse_on.asp.
Okay, I lived in Canada. Here’s what would have happened in a largish city the size of Seattle. I’ll use my old stomping ground of Montreal as an example for what would have happened.
You would have waited for one or two hours at a CLSC, a community health center. You would have been examined, and it would have determined that yes you need a CAT scan. Of course, they don’t have those machines there. It would be an older one, too — the typical MRI or CAT machines in Canada is ten years behind American technology.
You would then have gone to a private place to pay through the nose for this, more than you would in the US. Or, you would have received an appointment a month or two down the road for the scan at a medical facility. Hang on till then. In the event of an emergency, you could go to a hotel emergency room, and if it were an urban place on a weekend, waited 24-48 hours to be seen.
The German and Dutch models speak well for deeper government provision of health care. I lived the Canadian model for six years and never want to go there again. Earlier this year, a provincial health minister in Canada was forced to resign after he flew to the United States to seek treatment for an issue.
…i’m having trouble with the “comment reply” feature tonight…so i’ll do it the old-fashioned way.
@daves: you do correctly note that canadians have to pay for outpatient drugs; the counter to that is they buy those drugs in a price-regulated environment, which takes quite a bit of the sting out of the thing relative to the us drug consumer’s experience. (for the record, my pharmacy cost on this one was about $15.)
@sabutai: my larger point here is that if i had access to a primary care provider in the first place than i would have been at the doctor sooner than i was, and that would have been at a point when a cat scan would not have been required.
lots of care here costs more than in canada because we often initiate care at a later point in the disease process, especially if you’re one of the uninsured, and that’s true for everything from those annoying toothaches to cancer and cardiac disease; the savings would be enormous if we had a different system, as everyone else’s experience worldwide demonstrates.
as to particular systems: germany and the netherlands do well, as does switzerland, sweden, norway, and finland; japan operates a system that seems to me to be too administratively complex, but the quality of care is superb, and it’s hard to argue with results…until the bill comes in to the diet every year, i suppose.
by the way, consider this, regarding wait times in the usa:
you might be looking for a “workaround” to the shortage of general practitioners in this country.
one option would be to allow more patients to “self-refer” to specialists, but over time that might really turn out to be a “be careful what you wish for…” answer as the cost of specialist visits is generally higher than gp visits.
the potential workaround there? a two-tier system that pays less for self-referred visits…but you can already see how that could create its own set of problems and counterincentives…and that’s why designing these kinds of systems is very, very hard.