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Healing America: Canada

Misc notes
Some overlooked stuff before I move on.

One of my newer readers is from Japan, and goes back to Japan fairly frequently. She told me that Reid's tuition numbers are low -- did he ask his middle-aged doctors what they paid for tuition, without thinking about how that number would change over time? She says it'd be more like $6000/year at the elite and public National University. 6 years, + $3000 start fee, call it $39,000. Add in living expenses and you'd be looking at upward of $100,000, unless you were living with parents (likely?) or student housing is cheap. Against a GP income of $130,000 that seems non-trivial debt. At, if I understood her correctly, easier to get into but more expensive (like Phoenix U and other degree mills?) university, $100,000/year, which seems substantial for even a specialist

OTOH, she confirmed something I forgot to pass on: far from having waiting lists, the Japanese don't even seem to go in for appointments, expecting to be able to walk in off the street to see a specialist. (And without GP referral.) Waiting room, but not list.

Oddly, national insurance won't cover pregnancy or childbirth. "That's not a disease." (Assuming nothing goes wrong, I assume.) But local governments will step in with money for that.

French and German health payments are a fixed percentage of income. The French smart cards, carte vitale, were designed in the USA. But not for us!

Not part of the book, but Romney's latest gaffe leads to a brief description of Israel's health care system. Sounds like another Bismarck system, ironically enough, with about 8% of GDP spent. (My table says 8.7, that link says under 8.)


You know, what he calls National Health Insurance and I call Medicare was designed by Tommy Douglas, hero of Canada. Why isn't it called the Douglas movel, like the Bismarck and Beveridge models? I don't know if these are his own terms or standard in health economics. I guess he didn't design it from scratch; Henry Sigerist of John Hopkins told him him to gradually move to government payment of private medical bills, and Douglas cut the 'gradually'. Started with hospital care in 1947, in Saskatchewan, and it got copied by other provinces. In 1961 he launched Medicare, paying all bills; doctors went on strike for 23 days, then folded. A few years later the federal government got in on it, providing support and guidance for all the other provinces to do the same. Kind of like Romneycare turning into Obamacare, only without the same national public support. Douglas would later be rated the greatest Canadian of all time, beating A. G. Bell or Wayne Gretzky.

Huh, Romney could have had that kind of immortality, if he embraced and sold it rather than squirming away.

The system is called single-payer but that's true at a provincial level, so sort of 13-payer. Details vary: 100% payment, or small co-pays, or deductibles. Federal level sets a lot of rules and gives a lot of clout in negotiating drug prices, though you have to pay those unless you're poor, old, or chronically ill. Most Canadians have a private insurance too, to pay for dental, or nicer hospital rooms, or prescriptions. Since most of the actual medicine is paid for by Medicare, private insurance is cheap. (This pattern probably holds in the other countries too, just haven't gone into it much.)

Medical ecords are digital, and I infer accessible across the country. No filing cabinets.

A distinct feature is fear of a "two-tier" system where the rich get better care, so it is illegal to pay privately for procedures that Medicare will pay for. In a way that's more socialized than the UK, where specialists tend to be NHS employees but private medicine can exist in parallel.

Waiting lists

According to Reid, the US-conservative warning about dread waiting lists is true... for Canada. For France and Germany, it wasn't worth mentioning. For Japan, as above, they don't even make appointments. In the UK, his GP said a 2-3 month wait to see a specialist; that's comparable to the US. But in Canada he was told it'd be a year just to consult with an orthopedist, with another 6-8 months to schedule an operation after that.

(Oh yeah, I haven't mentioned that. Reid has a mildly bum shoulder -- limited movement, occasional pain -- so part of the book is his asking doctors around the world for help. So he has personal experience of how low-priority problems are treated. So that UK wait is to see an orthopedist about "my shoulder kind of hurts and we know why".)

A Canadian friend I told wasn't too surprised to hear that, especially in Saskatoon (population 260,000, in the middle of Saskatchewan.) Maybe Toronto would be better. I think he tended to live in more urban places in the other countries; I suspect Japan wouldn't look so cool in rural Hokkaido. And emergency times would be much better. But still.

OTOH, after an 18 month wait, he could get a free shoulder replacement. Beats the US, except for old people on our own Medicare. And the myth of Canadians flocking to the US for faster care is just that, a myth. (Never was plausible to me: how would most Canadians pay for US medical bills out of pocket? Especially when the exchange rate was worse for them?)

After an old man in pain had to wait 9 months and sued Quebec, the Supreme Court said in 2005 "no, you can't ban private care *and* have ridiculous waiting lists, that combination is unconstitutional", and the governments have been trying to cut down on waiting times. Still, it does seem a relative problem. And Canada already spends 10% of GDP on health care, so my usual answer to complaining Brits, "spend more you cheapskates", doesn't apply so well. (Though that 10% is after the decision, and might reflect increases in spending.)

Part of the problem is that in 1991, a commission recommended reducing the number of medical students. Reid calls the system underdoctored, and this agrees, with Canada having fewer doctors per capita then the US. (But Japan is said to have even fewer still. Odd.)

The doctor he talks to makes half as much as an American GP, but doesn't know how much malpractice costs since the provincial government pays it for him. Tuition costs for a medical degree run "half as much as they would be at a public university in the US", I'm not sure if Reid is comparing to public medical schools or to public undergraduate tuition.

And Canada looks poor only in comparison with other universal health countries, and at that does better than the UK in every simple metric except cost, let alone the US: longer life, lower infant mortality, much lower cost, people who really need care get it, and get it without going bankrupt.

See the comment count unavailable DW comments at http://mindstalk.dreamwidth.org/329914.html#comments


( 2 comments — Leave a comment )
Jul. 31st, 2012 08:30 am (UTC)
Wating lists are a serious issue in GB. I had to wait over a month to be referred to a wounds clinic for my infected leg wound (which my GP all too obviously didn't know how to treat). But American conservatives seem to believe that you might die of a heart attack while being queued, and the thing is that urgent conditions have no queues at all - you will always be admitted to an emergency department immediately. The admissions people accept your own assessment of how you are, at least to start with. The closest I have ever been to death was when I got a vicious infection in my right ear. I knew from the start it was bad, and I called an ambulance. They whined a bit about being called out for an ear ache, but then they took a look at my ear and immediately whisked me to the nearest emergency ward. It is for long-term conditions that you have to be queued.
the Japanese don't even seem to go in for appointments
The same is true in Italy. My father just walks into his doctor's waiting room when he wants a consultation. In GB, however, not only do you have to get an appointment, but if you have more than one condition to discuss, you have to get a different appointment for each. That is the kind of crappy idea invented by people with management degrees and no notion of healthcare, that have been butchering the NHS ever since the days of Meg Thug.
Jul. 31st, 2012 02:27 pm (UTC)
This claims Italy has an amazing number of doctors per capita, which would help; conversely the UK is at the US level, and as I mentioned a majority are GPs, not specialists.

Didn't know about the appointment splitting. I can see the logic, but... do they let you schedule a *longer* appointment?

Still not sure how Japan manages. Wrong data, or insane workhours?
( 2 comments — Leave a comment )


Damien Sullivan

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