I've also heard all these things about Canadian health care when I lived in New York, multiple times. As a Canadian who has lived in the UK, Canada and America, NHS and Canadian health care is pretty good. American health care with fantastic insurance is fantastic.
American care is actually really quite good, but the cost curve is very aggressive, it's something like 2x as much and doesn't cover everyone.
And inverse is true: Canadians believe in some fantastically weird things about the US system.
In my experience as a Canadian living in the US, I was basically shocked at how new, modern and efficient everything was, how service was relatively quick and how knowledgeable the experts were.
The Canadian system 'covers everyone' but it absolutely rations care, you will wait quite a while for non essential services, and in some cases a little bit longer than comfortable for other services as well.
My concern about comparing the various systems, is that I believe a lot of the 'exceptionalism' of the US system bleeds out into the rest of the world and we benefit from that quite a lot.
The challenge is: how do we get the prices down without materially reducing quality of care because even as their gross inefficiencies, it's hard to suck out just the problem costs without affecting the system as a hole - akin to 'losing weight' if you go on a diet, you're going to lose muscle as well as fat.
And you still have a double digit risk of being screwed even with a reputable insurer. Legalese, and fine script in medical services is a minefield no worse than American financial laws.
Exactly - every detail of insurance plans are a scam, and that’s not even enough so they’ll just deny valid claims and make you work for it.
An MRI might be “covered” but what if you have to spend 2 hours getting it approved beforehand and then 2 hours after proving that they said they’d cover it? Every time? For 4 MRIs?
The US system rations care as well. It just rations on the basis of who can afford care. It seems much more logical and humane to ration care based on how essential the service required is.
The US system also rations equipment based on more or less arbitrary bureaucratic determinations. Want to open a radiology practice with an MRI machine? Better hope the state lets you.
bbdog is correct to point out that rationing is mostly economic.
I do agree that there should be a humanitarian component to it.
In Canada, it's the other extreme: everyone is treated identically (theoretically) no matter what and it's illegal to sell medical services in most cases. The way 'around' the problem is to hunt down good doctors through the network and word of mouth. Literally the Golf Club is where you find out who the best docs are, and then you apply with them and hope you have enough clout/status that they take you on as a patient, because otherwise you just get 'stand in line at the clinics'. Doctors have their own hierarchy/status, and you want one on the 'inside'.
I think you may paint an overly rosy image of American health infrastructure. Where you live inside the U.S. has a huge impact on how "new" the available medical equipment is and how "knowledgeable" your local experts are.
What's more, most insurance is not generous. The insurer becomes the rationer of care by requiring value interventions before more expensive ones. Essentially any interest a state has in reducing costs an insurance company also already has. The main difference is that the insurance pool is probably healthier than the "everybody" pool.
Lastly, even if it is true America's system features better cutting edge medicine, I really doubt making the system less profit motivated would affect global health innovation. Perhaps a bit but quickly governments would realize they are going to have to invest in research more rather than purchase innovations from the U.S. This may actually increase the value proposition of research because there would no longer be a single locus drawing all competition for specialized labor.
"Perhaps a bit but quickly governments would realize they are going to have to invest in research more rather than purchase innovations from the U.S."
Governments are not this sophisticated or operationally nimble unfortunately.
We're in a pandemic, and I watch our Provincial medical leaders come out and talk almost every day, they're all smart, but they don't really understand what is going on - they don't have the data. But in a pandemic that destroys 20% of GDP, maybe it would be a good idea to have every single person who takes a COVID test fill out a questionnaire, so the data can be made available? Masses of unemployed young people that could be put quickly and succinctly onto large-scale contract tracing programs? Releasing communications apps to collect data, getting national level experiments running to determine the primary vectors of propagation etc. etc..
They are all professionals with good intentions, but this does not remotely translate into operational effectiveness. What we need is a 'Dwight D. Eisenhower' kind of leader for this pandemic but his type is long gone and we may not even recognize operational efficiency.
Even during a pandemic when much is at stake, they're limited by their own systems. A much broader strategy of 'creating innovation to make up for the American loss' would't work, even throwing $ zillions at it wouldn't solve the problem.
The sophistication of Canadian products, and ironically economic diversity has been going down in Canada, as we focus on being 'really good' at being a good 'Foreign HQ' country.
My most recent hospital visit here in Quebec was a little scary: broken equipment in the main hall, the water fountain out of service, having to wait in a cold waiting room all day for a very small issue with no updates (and I couldn't even leave the room), the halls were lined with elderly people in beds because they were overcapacity. I did receive competent care, but the economic stresses were visible.
And of course I don't doubt for a second how insane the US system can be for billing, financialisations etc..
I think the US should be looking towards the Dutch or Swiss models, not Canada or UK.
All of your characterization of the Canadian healthcare system nearly equally applies to the U.S. There are many older hospitals here with broken equipment and which become easily overwhelmed.
As for unsophisticated but well intentioned provincials that is a problem here as well. My own uncle passed from a cancer which was diagnosed as non-aggressive by a rural for profit hospital yet later rediagnised as extremely aggressive at a more sophisticated facility 2 years later shortly before his death. Geography and demographics create provincialism, organizational structure obviously has an impact on how we respond to that difficult problem but regardless of if a healthcare system is for profit or not, a nation is simply not going to commit the same resources to rural areas.
To my mind, the more surprising thing isn't how different the problems of American and Canadian provincial care are but how much the same they are.
Regarding
> Governments are not this sophisticated or operationally nimble unfortunately.
I don't know that this is true. Governments collect and act on a lot of public health information.
> In my experience as a Canadian living in the US, I was basically shocked at how new, modern and efficient everything was, how service was relatively quick and how knowledgeable the experts were.
As a Canadian I have no doubt that the US healthcare is better than Canada's in many ways… if you have the money to get that care. Or you're willing to go into debt to pay for it:
> Two-thirds of people who file for bankruptcy cite medical issues as a key contributor to their financial downfall.
However, Canada (and most of the Western countries) have lower infant mortality rates, lower maternal mortality rates, higher life expectancy, and a whole host of other health statistics. While often spending half on a per capita basis.
If you want to view it that way, fine, but it's far more than just a 'system'.
It's like saying 'transportation' is one key to a healthy 'manufacturing system'.
If you are sick and you can have the choice between going to an American Hospital or a Canadian Hospital ... you go to the American one, because they are better, point blank.
Sure. If we compare individual hospitals' ability to treat one hypothetical person with the highest quality of service and outcome, you probably are correct.
But my impression is that is like saying that you are a better dad if you spend all your money on one of your kids' Harvard education and let the other one fend for himself or go into debt, when you could've given them both adequate education at a less expensive college?
My position is simply that a health ecosystem where everyone gets adequate care for free or at least without going into crippling debt is preferred over a system where some get lavish care and others none. It's not like there's a thousand people dying of perfectly treatable diseases due to queuing in the Canadian health care system - but there are indeed people dying because they can't access basic care in the American system.
By the way: When is transportation not a key to efficient manufacturing? Do you think that the efficient solution is for factories to make every single part of their product on site? Does it not matter whether spare parts for machinery can be ordered and delivered within 24 hours instead of 24 days? Or did you mean that what I said was obvious, i.e. the American health care system is clearly less efficient for providing solutions to the population than the Canadian, but you want to stress the point that it is possible, in some cases, to get better individual care in an American hospital?
> America has lower life expectancy because of violence, not healthcare.
> That America has a cohort of poor people w/out care can easily drive a lot of the other numbers out of whack as well.
Other countries help probably take better care of their poor with social programs, which would include healthcare (IMHO). See also higher taxes, which allows for redistribution of wealth and paying for said programs.
> America has lower life expectancy because of violence, not healthcare.
Opioid epidemic, violence, and healthcare system all play a role, both in life expectancy and quality of life.
> By and large, I view the American system as delivering better specific outcomes, without regard to price, all other things being equal.
What does this even mean? If it means choosing random encounters for equivalent similar conditions, and ignoring price, the outcome in the US is consistently or on-average better, I don't think that's true.
If you mean “where can the best care be acquired, without regard to how many people have access to it”, sure, that may be correct.
It means they have better Doctors, better processes, better equipment, more of it.
It means if you have a problem, and want to 'be fixed' - you would much prefer to be in an American hospital - the only question is 'can you afford it').
Rich Canadians go across the border to the US all the time for care.
>> Two-thirds of people who file for bankruptcy cite medical issues as a key contributor to their financial downfall.
Only 4% of US bankruptcies are because of medical bills (https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0...). A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect.
European here who spent some months in Ontario. Canadian health care was definitely alright, at times a bit strangely organized but my medical needs were properly addressed (fractured my wrist badly, and was sick a couple of times).
US is great if you are properly insured and if you are able to navigate the system. But also extremely expensive in comparison so the value for the money you spend isn’t all that good in comparison
Yeah and also great doesn’t mean much out of context. Paying for the best possible health insurance doesn’t help much if it takes 10 years of premiums and partially paid annual deductibles to treat or even diagnose a health issue.
But if you are insured, does it matter how expensive it is?
Here in Germany we have public insurance and private insurance. If you have private insurance, you pay for health care yourself and then get the money back from the insurer later on. So you see what is actually being charged, and it is expensive.
If you are on public insurance, you never even see the bills. Often the private insurance actually has to pay for the public insurance, as health care businesses would be unable to survive without the extra money from the private insurance people.
Maybe if you see the bills because you are privately insured, they seem expensive. But perhaps they just reflect the actual real costs.
Even when the costs don't matter to an individual with insurance (though they usually do because most insurance is not all you can eat) they affect the overall quality of the whole system. For example, the U.S. delivers less care for more money overall than other nations because insurance companies, corporate hospitals, pharmaceuticals and care givers are largely not controlled in rent seeking behavior.
This means a greater share of GDP goes to pay for worse health outcomes. The cost of that lost GDP is measure in opportunity costs. That is GDP that could go to education, infrastructure, social programs or simply more savings for the median citizen.
Are you sure the US health care system delivers less care? I've read data about the health of the nation which seems bad compared to other countries (in relation to wealth). But I don't think that is automatically the fault of bad care. For example, if cheap access to food and cars make people fat, leading to bad health outcomes, it would not be the fault of the health care system.
It could be even worse, and a better health care system could make people be more careless about their health, because they would rely on being treated well enough to survive anyway.
Not saying any of that is the actual case, just that there are many aspects to consider.
As for controlling rent seeking behavior, wouldn't the insurance companies be interested in paying less? I don't see how private insurance facilitates uncontrolled rent seeking behavior?
It is very much a problem with public insurance, when patients never even see the bills.
We have measures that show Americans get less care per dollar. Not necessarily less care overall.
Regarding prices, yes insurance companies do negotiate prices to some extent but that has not controlled prices. See $20 asprin tablets given at many hospitals. There's a ton of reasons our private system has not done better controlling prices. It's hard to shop care. Insurers pass service costs onto employers who pay premiums who aren't consuming the care (the employee is). Medical companies find weird workarounds see medication couponing. I could go on. What it amounts to in the end is exactly rent seeking behavior, whatever the free market should be doing it is not. And there is no clear data that it is functioning more efficiently than a public system or at least a regulated market like Switzerland has.
In the end there's a reason that every developed country in the world other than America controls healthcare prices the same way. The government or a body backed by the government negotiates prices effectively fixing them.
Of course health insurance is a hard problem. No one ever said it wasn't.
> But if you are insured, does it matter how expensive it is?
yes...
I have what's called a "high deductible" plan, which means I pay 100% out of pocket until I rack up $1350 of medical bills in a calendar year. after that I only pay 10% until I hit a total of $2700. $2700 would not be catastrophic to my financial life, but it creates a moderate incentive to shop around on price.
But will health care providers adjust to your insurance?
Here in Germany, you get treated differently in some places if you have private insurance. I have actually avoided private insurance because I worried about too many unnecessary treatments (not sure if that was a good trade off - maybe if one day I'll get seriously ill, I'll regret that choice).
A bit annoying is that often the doctors won't even tell you that they are not suggesting a certain treatment because it wouldn't be covered by public insurance.
But what I mean is, possibly your treatment will somehow get cheaper once you are in the second stage of your insurance plan?
> But will health care providers adjust to your insurance?
most health insurance plans make a distinction between "in network" and "out of network" providers. "in network" basically means your insurance has already negotiated favorable prices with that doctor. so the simple answer to your question is yes. if the doctor is "in network" they will probably charge you less than they would charge an "out of network" patient. if I go to an "in network" doctor but haven't used up my deductible yet, I still pay the "in network" price. if you get a very large bill, I suspect there is further negotiation that takes place behind the scenes.
> A bit annoying is that often the doctors won't even tell you that they are not suggesting a certain treatment because it wouldn't be covered by public insurance.
in my experience, US doctors usually treat the details of insurance coverage as the patient's responsibility. the doctor probably doesn't know exactly what is/isn't covered by your specific plan, so I doubt that they would change their recommendations based on your insurance. a good doctor will certainly be sensitive to the fact that costs matter, so they might let you know that a cheaper generic drug exists or suggest that you try a certain treatment first because it is cheaper.
aside from the cost, I don't think there's any downside to having private insurance in the US.
I’m 41, lived in Canada till I was 31. Software Engineer, living in Boston mostly. I have always paid for the top tier health insurance benefits in my jobs. I have to say the experience in the US is waiting long for everything regardless and the User Experience :P is terrible. I spend so much time on calls clearing up confusions like who I owe money too, who replaces some health equipment I need, and etc. Privatizing seems to make for too much economic specialization that ends up meaning no vertical integration and thus a disjoint customer experience.
You are saying this when USA have biggest private hospitals in the world.
You may also be surprised what country contends with you for this place: Republic of India.
Some people say Gulf also has extensive private healthcare, but those forget that, I think, every Gulf country bankroll healthcare for their natives, and they do have near fully state funded hospitals. And yes, tons of Arabs in medical professions.
Most of "superelite" healthcare you see Gulf is just an extension of the medical market of the Subcontinent, and cater to nouveau riches to whom domestic market is not "elite enough" for their tastes.
> Privatizing seems to make for too much economic specialization
That alone isn't sufficient. Germany is built on private insurance (on top of something similar to Canada's government insurance) and it works just flawlessly. Usually they pay everything, you don't need to do anything. You skip all lines at the doctor, can directly go to specialists without asking anyone, etc. And on top of that private insurance in Germany is considerably cheaper than government insurance, while providing like 10 times the benefits.
If I had to name one thing I really miss from Germany, it's private health insurance. This was just like being in heaven.
Probably, but that's still about 10 million people with private insurance, which is 1/3 of Canada's population. The point is, private insurance doesn't have to be a nightmare. That is not the only factor. Actually I think private insurance generally had the potential to be much better than public insurance. However there seem to be a number of additional factors that make US private insurance such a nightmare.
> Actually I think private insurance generally had the potential to be much better than public insurance
Why? Maybe private care is better than public care, i don't know, but insurance? Swisslife (one of the best/most efficient in my country) reimburse 65 to 67% of their anual income, so roughly 33% of what you're giving them goes into administration/coordination fees. Public insurance? 20% of the money they receive via taxes are used for administration/coordination.
So if i had a choice, i would pay a premium on public insurance (more taxes, or instead, asking my bosses to give the 120€/mo to the public insurance instead of paying swisslife). Better ROI.
> That alone isn't sufficient. Germany is built on private insurance […]
The difference is profit motivation.
Germany does have private insurance, but there are regulations on what insurances companies can have margins on:
> As of 2020, salaried workers and employees who make less than €62,550 per year or €5,212.50[28] are automatically enrolled into one of currently around 105[29] public non-profit "sickness funds". The fund has a common rate for all members, and is paid for with joint employer-employee contributions. The employer pays half of the contribution, and the employee pays the other half.[30]
> Insurers are required to offer this basic insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans.[3]
> And on top of that private insurance in Germany is considerably cheaper than government insurance
Not at all. A significant portion of the government insurance is paid by the employer, so it ends up cheaper for the individuals. Also, children are included in the government insurance.
About 15 years ago a friend of mine, who's a physical therapist originally from Canada working in the US, made an interesting observation.
In Canada, MRI machines were available only at a few major hospitals. It took months to wait to use one. In Chicago, where we were living at the time, she said it seemed as if there were an MRI machine on every block.
I think the situation is different now, but I think the observation is quite telling.
About 20 years ago, Buffalo NY had more MRI machines than Canada (not coincidentally, it's also the closest US city to the Toronto-Mississauga and St.Catherines-Hamilton areas.)
Living in Canada and I've heard people pay for MRIs on the south side of the border just because an MRI to see if there's ligament damage in your knee would take 6 months. There's definitely areas where care in Canada is excruciatingly slow.
In my own anecdotal experiences (my own and from my friend circle) a lot of more chronic/non-urgent problems take forever to get looked at by a specialist in Canada.
You can't compare public care in Canada with private in the USA. Though you wait six months for that public MRI, but it doesn't cost you anything! Yes, the waits suck, and they are related to having a low number of these machines in our public systems, compared to other countries. We have private imaging clinics in Canada which will serve you promptly, for something like $700 and up. Could it be that people are going to the USA simply because they are finding better deals than that? You know, get cheaper groceries and gas, and swing an MRI along the way, kind of thing.
I have a plan from Kaiser, which is a non profit health care system in the US. They do everything in house, which is pretty cool. I asked my doctor for a blood test, and he gave me a quick ticket, then I went downstairs, gave them my ticket, and they took the blood test immediately. Then about 6-7 hours later the tests were available from their website. I have to have an endoscopy done, and it's also done in a different building adjacent to the doctors office.
Interior BC Canuck here. The system is miserable. My gf has mental health issue, short of actually attempting suicide, there is pretty much no way to get access to any psychiatrist [I guess she wouldn't be a burden on the system if she succeeded...]. Her father had bloody urine, and was recently denied cancer appointments. And on top of that private practices are straight out illegal.
Also, as personal experience, while living in Quebec, as I was in-between visa, I had to walk for 2 days on a broken foot as the ER wouldn't check me unless I paid ~1000$ for a consult. I was lucky to be be able to go to a private clinic, paid $50 and was done.
I really wish I could just pay to access a private practice...
NDP has been in power since 2017. From 2001 to 2017, Liberals were in power. Do you have any evidence that the quality of care has gotten worse in the past three years?
I am sure things are bad now because of the COVID-19 lock-downs, but I do not believe, ignoring the COVID-19 disruptions, quality of medical services are bad in BC or have gotten worse in the past three years.
I can stack on my personal anecdotes about how the BC health care system has treated me incredibly well. I've gotten fast access to surgery. I've had quick access to specialists. I have a family doctor.
If you're not a citizen/landed immigrant/registered with a visa/etc anywhere in Canada you're going to see the raw costs of medical care for sure. You mention being in between visas. Depending on your accent and skin color you may have also experienced the systemic racism that exists in Canada that no one likes to admit exists.
At the end of the day, BC medical care works great if:
1) you can navigate and advocate yourself through the system
2) you have extended health coverage (usually through an employer but can be bought privately)
3) you have a doctor/nurse that can help connect you into the expedited route in the system
4) know when and how to access the secret private health industry (ie pay $700 for an MRI tomorrow instead of waiting for years for free ones) plus having the ability to pay for it.
I've seen this over and over. It's super charged squeaky wheel syndrome.
I'm from the United States and I've lived in Canada for the most part of the last 8 years.
I'm from a middle-class family, but for reasons that aren't totally clear to me, my family didn't really have health insurance even though my father was employed. We were well-off enough that I was able to come to Canada for school, where I went to UBC.
These are the things I've experienced:
- You are required, as an international student, to sign up for the provincial healthcare program, MSP. I believe I paid $75 a month for health insurance.
- I was able to see a doctor very early on (mood disorder) and treatment was very satisfactory. I liked my doctor, I liked how the system works. Is it perfect? Of course not.
- I had an episode which put me in the hospital for over a month (would have been the start of 2016). At the time, I had not notified MSP of the change in my address, so I had stopped receiving bills and paying for them. When I was hospitalized, they told me that I owed about 3 years of MSP payments (around $3k). In essence, I paid 3k for a hospital stay that lasted close to 40 days.
- After being discharged from the hospital, I was assigned to a mental health team. It wasn't near where I lived, so I was able to transfer to a closer one. The team consisted of a psychiatrist and, in essence, a social worker who monitored my mental health and encouraged me to do things like group activities to make friends who were also dealing with mental health issues.
- As part of my hospitalization, I tried art therapy, which I continued to engage in after being discharged. Therapy was a bit expensive (think around $150 for an hour and a half, which was a bit much for someone who was just getting started working), but it was effective and helpful.
- I left the mental health team and began seeing a psychiatrist through UBC's student health services. I still see them even though I've graduated. I pay nothing for these appointments.
- I work full time and have private health insurance through my job. This insurance covers my current CBT costs for the most part, as well as providing an HSA plan which I use to pay for medication that isn't covered by MSP.
I've also done things like participated in a university study on perfectionism (12 weeks, group therapy situation).
I think the biggest takeaway from my experience is that, as a result of my mental health disabilities, I would not move back to the United States. I don't feel comfortable with the idea that healthcare would be tied to my employment. If I lost my job and was unable to adequately care for myself as a result, it would likely be close to impossible to find a new job!
To me, it feels like Canadian healthcare is not necessarily a perfect system, but it is a system which works well for most people. People aren't afraid of being sick, they're not afraid of medical bills causing bankruptcy, and they are more able to freely live their lives because the government is actually in a position to take care of its citizens.
The MSP is essentially a head tax. It did not come close to covering the cost of health insurance (Which was almost entirely funded from general tax revenue - income tax). If you were a student, and not working in Canada during your school years, it's likely that you weren't paying very much into the system.
The MSP was also eliminated this year, so now healthcare in BC is fully funded from general tax revenue.
NPR has a fetish, like many liberal media, that if only americans better understood healthcare, we would all live in an egalitarian utopia.
I am absolutely happier having american healthcare than canadian. Admittedly, that's because I am of the 80 percent of people who get decent health coverage via my employer. A significant minority of Canadians agree with me, so it's not like this is some radical position.
There is a famous story in canada where you could get CT scans for your pet the same day, but non-urgent scans for humans had like an 8 month waiting list.
My great grandfather had to wait 6 months for cataract replacement. He considered going to North Dakota to have it done, as it was preventing him from working. So now canada has inadvertently fallen to the same trap as everywhere else: if you're wealthy enough you can just go to the us for care. Everyone else has to wait.
I've tried to say these sorts of views on reddit, but just get called a troll or a liar. I'm not trying to argue that public healthcare isnt better in some ways, or even that americans shouldn't consider it. It's just that these sorts of outlets tend to have a rosey view and give this impression that dissent arrises only from ignorance, and I must be some evil, Mr Burns-esque robber baron.
> I've tried to say these sorts of views on reddit, but just get called a troll or a liar.
Just in this thread people are downvoting anyone praising the US system and talking about the shortcomings of the Canadian one. I've had a Canadian doctor tell me first hand that the US healthcare system is far superior provided you have insurance.
The state of insurance undercuts the quality of the services, actually. It raises costs, changes treatment decisions, and has generally warped our system towards one focused on lucrative, worse-outcome behavior on the part of doctors and hospitals. Much of this related to the putting off of preventative or early treatment due to OOP costs; people gamble that their conditions won't worsen so that they won't be forced to go into debt for treatment (if they can even access credit). Many lose that bet and end up having to pay orders of magnitude more for late treatment.
Speaking personally, I had surgery for a long-standing condition, which the surgery failed to correct. Under a different system, my issue might not have become chronic, I might have been able to make a better decision regarding the surgeon and surgery (e.g., getting a second opinion, follow-up imaging, etc.), and I would not have missed a follow-up appointment after losing my insurance. Because I'm an American, living under this system, the circumstances of my treatment and subsequent outcomes were drastically shifted towards unsatisfactory.
Actually, compared to OECD countries, the quality is pretty bad.
The US is at or very near the worst among OECD countries in: life expectancy at birth, healthy life expectancy, rate of obesity, disability-adjusted life years, doctors per 1000 people, deaths from treatable conditions, rate of mental health disorders, rate of drug abuse, rate of
prescription drug use.
It would seem health insurance companies charge a lot of money for not such great healthcare.
Those measurements you cite are not direct measures of the quality of healthcare services. Many people have poor health outcomes because they cannot afford to receive services from a healthcare provider. People often wait until their health situation gets out of control, because they are afraid to incur burdensome medical bills.
> I don't think anyone doubts that American healthcare is technically of good quality
Good healthcare is available to some in America, but not all healthcare in America is good.
> Its the insurance system that is broken.
Financing is the root cause of some of the other problems, but there are absolutely problems with care quality, too, even if resolving financing issues would lead to those going away.
Isn't there private healthcare in Canada? Here in Greece, you can wait a few months for some tests if you want to use insurance and get them for free, or you can pay (or use private insurance, if you have it), to get them faster at a private clinic.
Healthcare providers are not allowed to charge publicly-insured patients for covered services. Insurance companies are not allowed to insure for covered services. So for covered services (e.g. lab tests and doctor visits) the only available options is public. For non-covered services (e.g. ambulance, dental, prescription drugs, etc.) you pay out of pocket or use private insurance.
Many healthcare providers themselves are private. For example, doctors are independent contractors, not government employees, and their offices are private businesses. But they get paid for services by the government (why we call if a single-payer system rather than a public system).
Maybe things have a changed in the past few years, but I knew an orthopedic surgeon with a private practice in Vancouver. The workaround was that he charged a flat hourly rate, not a per-service fee. He specialized in knee surgery and also worked at a local hospital, so you could either wait 3 to 6 months for him to fix your knee at the hospital, or you could book him sooner at his private practice. That sounded like a win-win to me.
A. It's not a true win-win. He is not creating and selling extra treatment capacity. The time he spends in his private practice is the time he would have otherwise spent in the hospital. The same number of patients end up receiving the same number of services. But now, instead of need and urgency determining who gets the services first, it's money.
B. It is not a loophole. The federal government fines provinces who don't rein in private billing. British Columbia loses millions of dollars in Canada Health Transfer every year because of lax enforcement though. BC lost $15.9 million in 2018 and was on track to lose $32 million in 2019, but they started enforcing the law better.
Apart from a terribly selfish attitude, I'd like to see proof of the wait for CT scans. Australia has mostly socialised healthcare and I've always had xrays same day and CT, Pet and MRI within a couple of days at most.
The complaints I frequently hear from Americans regarding 'socialized healthcare' never ring true based on my experience in countries like the UK or Australia.
For Canada, the data is easy to find, since it is all public. Here is average and 90% (when 90% of the patients have received care) data for non-urgent CT scans in the province of Alberta. Before the pandemic hit, average and 90% were approximately 12 and 20 weeks. Due to the pandemic, now they are double. Ontario is doing much better. You can see their data in the second link.
As a Canadian living in the US, I have to disagree.
The fact that 27 million people (1) live in the US without health insurance alone is a big enough reason to know that that US system is not working. People should not die or go bankrupt due to not having insurance.
The current system might work for the rich and privileged but that is not good enough.
The thing that always makes we wonder in these types of online health care discussions, is why Medicaid and Medicare are ignored. This is a genuine question, since I'm privileged enough to have a job with good health insurance, and I don't have personal experience with those programs.
I don't think having everybody insured would be the criteria for it being working either. I came across a lecture about how metabolic syndrome treatment accounts for a large chunk of health care spending (75% [0]), and there's a lot of blame put on added sugars and processed foods. A large push for preventative care would be ideal.
>The fact that 27 million people (1) live in the US without health insurance alone is a big enough reason to know that that US system is not working.
That's 91-92% coverage of a country of 330 million.
91% of Americans have medical insurance, whether through their employers, or government programs like Medicare/Medicaid. That's compared to 95-97% in other developed countries because there are always some people who fall through cracks, like (say) a Canadian who doesn't get a new provincial health care card after moving, or a German who neglects to buy into a new sickness fund after changing careers. The only such systems with actual 100% (or as close to it as possible) coverage is something like the UK NHS, which does not have a requirement to show a membership card (because, well, there isn't one) to receive treatment.
PS - Obamacare did not greatly expand coverage. 85% of Americans had medical insurance pre-Obamacare.
There are things I'd certainly improve about the US system—decoupling primary healthcare coverage from employment, for one—but the way people online ~~lie~~ exaggerate it's not surprising that so many non-Americans believe that every American is one hangnail away from bankruptcy.
>People should not die or go bankrupt due to not having insurance.
Only 4% of US bankruptcies are because of medical bills (https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0...). A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect.
> Admittedly, that's because I am of the 80 percent of people who get decent health coverage via my employer
Have you ever thought about what would happen if you want to take 12 months off work so you can spend time with your kids, learn a language or just some personal time?
Have you looked into how quickly your insurance would drop you if you developed a serious illness, or suffered a major auto-crash with extremely expensive and life-altering medical conditions?
Tying ones health to their employment is barbaric, and as someone that has never suffered such a fate, I consider it the next step up from slavery.
i.e.
Slaves - work or you don't eat/live.
US heath insurance - work or you get bankruptingly-expensive healthcare.
(Rest of the developed world) - work or not, healthcare is for everyone.
Ask your employer how they feel about paying for your healthcare. Whatever your opinion of the quality of healthcare you get may be, it is an undeniable fact that the cost is rising and has been rising at rates far above the rates of inflation. This has been happening for a long time, but it really accelerated after Bush signed a law that said Medicare was not allowed to negotiate drug prices. (Although, I am sure there are other reasons).
If you are lucky enough to have an employer that loves you so much that he/she is willing to pay ever increasing cost for your medical care, good for you. But I can tell you that you are in a tiny, tiny minority. As things currently, stand medical care costs are scary high and they are getting higher every year at a very scary rate. And most employers are looking at ways they can limit their health care costs, most of the solutions resulting in limiting benefits for employees.
> I am absolutely happier having american healthcare than canadian. Admittedly, that's because I am of the 80 percent of people who get decent health coverage via my employer.
Do you still have coverage if you get laid off? For how long? For kids too? That’s what freaks me out about the US system, is that it’s tied to employment to a high degree.
This pandemic must have led to tons of people being laid off. Many of them got laid off and then they (or a family member) got Covid. How long after being laid off are people normally covered? How long is coverage for family members on the employee’s insurance after they are laid off?
I wouldn’t say care is better under my single payer than it is for US white collar employees, but I assign a massive value to the fact that I don’t worry about insurance or money if I get sick, have a child, or have a chronically ill child.
"right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102% of the cost to the plan."
Yeah, no, that's not the same thing at all. As a Canadian I have health coverage I can, y'know, live with regardless of whether I'm employed or not. And buying coverage in the US (with a pre-existing condition) was absolutely not worth it (even considering the wage gap) when I entertained a few offers in the early oughts.
Staying here means I have substantially better freedom of movement and negotiating power. In the US the "freedom" to not have healthcare just seems to mean that everyone has the "freedom" to pay more - and often for less.
Look, I absolutely agree. I am actually admitting my privilege.
Even if it's the right thing to do, a lot of people are going to be opposed to it if it hurts them (even marginally). I think NPR sort of overlooks this, and focuses too much on the poorest 10 or 20 percent.
Certainly we need to care about the poor, but the rest of the people matter too.
Cataract surgery is not urgent. In Canada, they ration by need, not the ability to pay. It's also a problem that is not generally characteristic of health care systems. Overall health outcomes are better by the vast majority of metrics.
Even if you have good insurance, wait times can be bad. For a point of reference, someone close to me had a potentially fatal condition and wasn't able to get a specialist appointment for 4 months. That sort of thing isn't uncommon.
A lot of people have pretty good insurance through their employers, but part of the point of a system like Canada's is that if you lose your job you still have the same insurance. Similarly, if you want to change jobs or launch a startup, health insurance isn't the thing that's holding you back from that.
With the ACA, things are at least a little better than before: individual people can at least buy insurance, which wasn't the case before if you had a pre-existing condition and didn't live in a state with a subsidized program (like Oregon's OMIP).
A criticism I've heard of Canada's system is just that it's under-funded. They could raise their taxes a little and divert more money to health care, and it would improve some of these wait times. I don't know how true that is, though, and how much of a legitimate problem it is. Canada definitely pays far less per capita for health insurance than the U.S.
I had a coworker that was employed with health insurance for 25 years, never used it. Got laid off and then right after COBRA ran out had something major go wrong. Had to get a second mortgage on his house to pay his medical bills.
Seems 'unfair' to pay in for almost 30 years and have that count for nothing.
> I've tried to say these sorts of views on reddit, but just get called a troll or a liar.
I think it would help if you didn't start by saying that 80 percent of people have employer coverage, decent or otherwise. Because it's both false and easy to check.
Okay, you're right. I should have just said majority.
I didn't mean it statistically, just that most americans are insured, either by purchasing privately or by their employer. It's an internet comment not a journal article.
Saying things you don't mean might be why people on reddit accused you of being a troll or a liar. I don't have proof, but it seems like a good place to start.
> It's an internet comment not a journal article.
"It's the internet so I can say whatever I want regardless of facts" is not a mindset conducive to meaningful conversation. I'm guessing again that it might be why the people on reddit dismissed you.
You might not think that this is important, but, speaking to your complaint that outlets "give this impression that dissent arrises only from ignorance, and I must be some evil, Mr Burns-esque robber baron", it seems pertinent that the available interpretations for people encountering what you said are that either you didn't know that the real number was far lower than what you said or you knew and were intentionally misrepresenting things.
In the U.S. healthcare plans typically do not cover dental. In particular, neither Medicare nor Kaiser provide dental coverage AFAIK. Dentists are quite willing for patients to pay for services directly. They'll typically charge less than what even insurers reimburse as insurance billing is so time consuming and therefore costly. There's not much negotiating as when you pay directly you're pretty much paying market rate, unless you live in a rural area where there's little competition--i.e. no market.
Market rate in Mexico is undoubtedly lower than in the U.S., though. Speaking of Mexico, they seem to have a pretty solid public healthcare program. Maybe expectations are lower, maybe people are sufficiently contented by access to relatively unregulated pharmaceuticals and medical practices regardless of poorer outcomes, or maybe griping doesn't make it across the language barrier to American news, but it definitely seems like there's less anxiety about healthcare in Mexico.
A person I know went to Mexico for a semi-elective jaw surgery. It was a great experience: more personalized attention than the US, high quality, and they paid much less.
Yes, I’m hoping everyone realizes that’s part of the point. We don’t actually even have “health” coverage, even those with what most in the US would consider top notch coverage.
>Our neighbors drive from California to Mexico for dental work. Often. They have Medicare, additional coverage from a union, and Kaiser.
As mentioned, dental coverage in the US is typically decoupled from medical coverage. (This is the same in Canada.) Your neighbors go to Mexico purely because most things, not just dental work, is cheaper there, as opposed to said dental work not being available immediately. Very different from why Canadians typically travel to the US for medical care, which is either a) to avoid long lines (and legislative prohibition of private clinics to pay more for quicker access), or b) expertise that isn't available in Canada.
Health care in the US is bimodal -- if you have good insurance and are wealthy, you'll get the best care in the world.
If you aren't rich, you'll get care on par with developing nations. And our life expectancy reflects that. If you break down life expectancy by wealth, wealthy people in the Us live longer than wealthy people in most other places, but poor people fare far worse.
I hope we can find a system that maintains our exceptional outcomes while expanding who that applies to. I think the systems in France and Japan are pretty good. France has a public/private hybrid system and Japan has public insurance but also employer based insurance.
Medical bankruptcies represent 62% of all personal bankruptcies.
39% of those who have issues with medical bill payments already have employer insurance
I think you're right that if you have good insurance and you're wealthy you do ok, but it's easy to have employer medical insurance, have a serious illness, and have serious issues being able pay or expending a significant amount of personal wealth during that serious illness.
Jeff has to work to be wealthy. Otherwise Amazon would just skip away. Like it or not Jeff is the driving force behind Amazon's success. And he has an insane work program every day.
That's ridiculous. First off, I'm sure he's already put things in place in case he is suddenly unable to work, like if he gets sick or dies. Secondly, I doubt they would lose all their value if he left.
If Jeff stepped down today, he'd still be a billionaire, and besides he can just sell some stock first. He's probably already got a few 10s of millions just sitting around in cash "just in case"
I know a lot of people who don't have to work, they simply choose to work, in large part to get the insurance. They are usually older and near the end of their career, before medicare kicks in.
That sounds like having to work to me. It seems like a fairly thin distinction - especially if the choice is being not able to afford health insurance or working.
Table 2
Debtor said medical bills were reason for bankruptcy 29.0%
Medical bills >$5000 or >10% of annual family income 34.7%
Mortgaged home to pay medical bills 5.7%
Medical bill problems (any of above 3) 57.1%
Debtor or spouse lost >=2 weeks of income due 38.2%
to illness or became completely disabled
Debtor or spouse lost >=2 weeks of income to 6.8%
care for ill family member
Income loss due to illness (either of above 2) 40.3%
Debtor said medical problem of self or spouse 32.1%
was reason for bankruptcy
Debtor said medical problem of other family 10.8%
Any of above 62.1%
>Medical bankruptcies represent 62% of all personal bankruptcies.
Only 4% of US bankruptcies are because of medical bills (https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0...). A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect.
It is not just Health "Care" in the US that is an issue. It is also the Health "Administration/Logistics" due to Insurance Company middle man mafia. Every time you visit a doctor or a hospital, you will never know exactly how the bill is and you will be chasing to find out who to pay when at many times. I am not even talking about the outrageous cost yet.
My providers all promptly send me bills, they want the portion of the bill the insurance didn't pay. There's frequently lots of them, but the bills are clear and arrive promptly once insurance has settled.
Have you ever tried figuring out what a medical procedure will cost you before having it done? I’ve tried... and it can be outrageously difficult and time consuming.
For context, here's another Twitter thread from Mr. Potter (the Cigna former CEO in question) regarding his and his industry's role in pushing narratives about the Canadian healthcare.
I was a software engineer in America's largest company for healtcare payment transactions and let me tell you, as stated in the article, we will justify our existence and do anything in order to continue existing so that the cash flow can continue. We automate the writing of templates that say, "Sorry Mr/Mrs. Smith, your insurance claim includes x-y-z specific services which make this claim invalid, so you must experience financial turmoil as a result." Sometimes the eligibility period would close with a hard deadline, despite healthcare delays. I also wrote code to reject or approve financial transactions for claims.
The justification for this company specifically is that paper payments need to move to digital and make it as efficient as possible because if not, someone else might get it wrong, and _they_ could make it even harder for Americans to get their finances processed in a timely manner. At the same time, digital payments and notifications makes it much easier to obscure who the point of contact should be when things go wrong and you want to make an appeal. Upwards of 80% of expenses for some healthcare transactions companies come from things related to paper checks, but I don't think anyone would point their finger at those fees and say "this is the reason why US healthcare is much more expensive than the rest of the world".
Especially during this pandemic, when we didn't want to dirty our hands further or deal with legacy healthcare IT code, we tossed it over the offshore wall in Taiwan and handed it to their armies of software contractors, some of whom even coming from India to live in Taiwan in order to have this opportunity.
The patients (called "consumers" or "members" in IT insurance parlance) are not actually the customer. The customer is the insurance companies like Aetna ("payers")
At some point you have to question if you want your career to be built on automating the rejection of millions of people and know that your code contributes to perpetuate current existing healthcare system in US. However, the thing is that the skills of a software engineer is becoming fairly routine and common, so unless you are something like Director of AI or Mr/Mrs. Design-Lead-for-Rare-Skillset, you are also fairly replaceable. Software engineers are told what tasks need automation, and they implement it. If not, hire a different one.
I'm also aware of and have lived under the Japanese healthcare system, and perhaps like the Canadian system, I know how much more reasonable it is despite the lesser amount of private access. It's also a myth that the US contributes far higher to medical R&D than the rest of the world, as Japan has close to the same proportion of R&D, yet Japan doesn't have nearly the same consumer costs as high as the US. Consider that ≈0.65% of American economic output (measured by GDP) goes toward healthcare R&D, while ≈0.40% of Canada’s economic output goes toward healthcare R&D, and Japan ≈0.50 (page 79) [1]. Every Japanese/Canadian citizen, on average, can afford to pay more proportion per capita on healthcare R&D than the US. Still, on some rankings, America ranks as one of the least efficient healthcare systems: 50 out of 55 on a Bloomberg index for developed nations [2]. The US has the highest healthcare spending, but does it at least have a return? Life expectancy says no [3]. Yes, it is arguable that life expectancy is too simple, but it is a simple way to intuitively compare healthcare system outcomes across different countries.
It makes me happy to know that Americans like Potter in the article are trying to find redemption for their past participation. I hope to find the same and find better ways to use my skills
[1] World Health Organization, World Health Statistics 2016: Monitoring Health for the SDGs Sustainable Development Goals. 2016: World Health Organization. bsanr2↗
>The patients (called "consumers" or "members" in IT insurance parlance) are not actually the customer. The customer is the insurance companies like Aetna ("payers")
This sounds frighteningly like the "overmind" theory of AI, wherein a system (perhaps the internet) becomes to higher order brain functions what they themselves became to the brain stem. The higher order systems pass currency (data, money) between themselves, over the heads of the lower order entities, making decisions that may or may not be in the latter's best interests (even though there is a clear hierarchy of existence that relies on the latter). Essentially, we've created a system where massive systems negotiate our life and death outside the public's purview and influence. Musk et al. warn about the dangers of AI, but with our existing systems, it seems that we're already there.
As healthcare networks expand, the US developing most of the attributes used to criticize national systems.
In my region, 5-6 hospital networks in 2000 have boiled down to 2 in 2020. Practices get gobbled up by the networks or form their own little cartels. For example, in my region a single nephrology practice controls 90% of the business in that speciality.
Through United I was paying $1300 a month with a $5000 individual deductible for a family plan (only included routine pediatric dental). $80 specialist copays, $40 routine visits. ER care is only covered a certain % no matter what it is and there’s an additional $250 deductible just for walking into the hospital.
Still paid roughly $8000 out of pocket for a natural child birth and prenatal care.
It was so bad I took a full time job just for the insurance.
There’s an out of pocket maximum ($xx,xxx) that kicks in at some point I think? I’m honestly not entirely sure if that covers everything in an emergency... healthcare being a leading cost of bankruptcy is no joke. I don’t think the average person really understands how close they are to financial ruin.
The monthly payment is a fairly meaningless question. I recently reshopped health plans in southern CA. For a family of four, different rates went from $700/mo to $2900/mo, but they all had different copays, different test, ER, hospitailization costs. Different deductibles, different allowances and disallowances for deductibles. Different out of network payments minimums and maximums. Different drug family costs. There is zero comparability.
There are a lot of people saying “my employer insurance is great!” which is nice... but aren’t you frustrated that it’s tied to employment?
I’ve contracted before and insurance is a nightmare. I stopped contracting and took a full time job because of it... even small startups often get terrible options because they’re not at the size to have any negotiating leverage.
Without a universal solution we’re kind of in a state of light indentured servitude. If it weren’t for healthcare costs I might not even work full-time... I’ve considered moving to canada just so I can be free from the burden.
I don’t think most Americans understand the mental weight of having to think about insurance at critical life junctures... even if you’re willing to disregard the millions of uninsured lives that fall by the wayside.
I have to think about premiums, copays, billing codes, in and out of network coverage, have awkward pricing conversations with doctors, call to fight denied claims... and sometimes I still get blindsided if for some reason lab work needs a second set of eyes (sometimes those eyes are in the same facility and out of network). Oh and for some reason my teeth aren’t covered as healthcare?
We’re boiled frogs with this stuff... people still think we have the best healthcare in the world but disregard the fact that it’s only available for the rich; we’re generally well out of the top 10 otherwise. I grew up in a rural area and I know multiple people who literally pulled out their own teeth because they didn’t have dental insurance. We need to start taking better care of each other.
It's amazing how brainwashed we have become. Employer tied healthcare is one of the worst things that happened to Americans in my opinion. It justifies the insurance middle men, gives employers more power for no reason and takes away choice from people. And no, just because you can buy insurance yourself, you cannot beat the "group" rates that companies get from insurance companies. I saw all this as a Small Business Owner/Employer who would rather give my employees more cash than dealing with shitty insurance companies and their monopolies.
Also, real cost would never go down until people realize that employers subsidizing outrageous premiums is never going to force the market to lower costs (mostly inflated due to insurance companies in the picture again for EVERYTHING).
The current "system" is very hostile to small business. I don't think the average person realizes how bad it is.
I abandoned a financially successful independent contracting business of 15 years and went back to being an employee (ugh) because the Republican efforts to repeal the ACA freaked me out. I'm old enough that my wife and I both have some pre-existing non-chronic conditions, and I have a young daughter. Paying ~$20K of premiums annually for the privilege of having a $13K deductible was grudgingly acceptable to me. The uncertainty was not. The stress of wondering if insurance was going to be available year-to-year (in the final year I operated the business my County had exactly one marketplace plan available) was extreme.
I happened to get a job offer from a Customer. I decided that, though I swore I'd never be anybody's employee again, it was irresponsible in light of the efforts by the GOP to repeal the ACA to continue gambling that insurance would be available.
I had a taste of being uninsured in 2014 when, on pre-ACA grandfathered insurance, I had to pay out-of-pocket for treatment related to a pre-existing condition that wasn't covered. The idea of just how close we all are to a medically-induced bankruptcy really hit me at that point.
My quality of life is much worse now. I used to bill in 20 hours what I now have to report to the office "40 hours" to earn. I used to be able to spend more time with my family. I used to have the flexibility to make decisions about how and when I wanted to work, take time off, etc.
My Customers, some of whom I'd worked with for 10+ years, ended up stuck going with drastically more expensive (and less attentive and skilled) "managed services" companies to service their IT needs. The emails and calls that I get regularly asking for my help, along with the out-right statements to the fact, tell me that the situation for them isn't better either.
I’m an American getting single-payer health care through the Veterans Administration in the US.
My first appointment was in 2007 and there was such a concern that vets would be ignored the way they were after Vietnam that the pendulum swung the other way.
I’d typically not wait more than 48 hrs for an appointment, I had no copays, prescriptions/bloodwork covered 100%, physical therapy when I got injured, etc.
As a transitioned veteran in college with no insurance it was a dream.
Now that I have private insurance through work, I only keep it for my family, and I continue to use the VA for all of my healthcare.
It’s not perfect and wait times in places need to improve but for the most part, if you need help, you get it.
As a Canadian, my experience with our health care system has not been great.
I had to wait almost a decade to get a family doctor.
Before I had a doctor, I had to wait 10+ hours in an emergency room whenever I needed a consultation or a prescription (which you need if you want to see a specialist). Now that I have a doctor, I can usually get an appointment with them within 1-2 months, and with a specialist within 6-12 months (after seeing my doctor). It guess it works if you're patient.
I once tried to get some vaccines before a trip to Asia. I called 2 public clinics and was told that I couldn't get a tetanus booster until 3 weeks later. I called a private clinic and they quoted me 3 x $200 for rabies (which was out of stock for a month) and 2 x $400 for Japanese encephalitis.
I decided to get them in Bangkok. I booked an appointment online, 2 days before arrival. I think I paid $100 in total for a tetanus shot, hepatitis A/B antibodies test, hepatitis B shot, Japanese encephalitis shots (2), rabies shots (2).
Of course, vision and dental are 100% out of pocket expenses.
I also find many drugs to be much cheaper in the US than in Canada. Some common drugs are 5x more expensive in Canada than in the US, when I look at GoodRx. The same seems to apply to blood tests.
However, I can't say I'm a fan of the US health care system. The obscenely inflated prices and the lack of price transparency puts those without insurance in a tough spot. I now wonder how COVID-19 affects those who rely on medical tourism for treatment.
> Before I had a doctor, I had to wait 10+ hours in an emergency room whenever I needed a consultation or a prescription
Didn't you have access to walk-in clinics? They are everywhere and you rarely have to wait an hour to be seen by a doctor. Emergency rooms are intended for actual emergencies.
My mother lives in BC. She is old and has had multiple problems. She has been in the hospital a few days every month for the last 4 yrs. She never pays anything.
My mother in law is in a similar situation in the US. It costs thousands for a hospital stay with insurance. My wife has spent a few hours every month arguing with the insurance company.
Our retirement plans are in Canada. There is no way that we can afford to retire in the US.
I've had far more experience with both American and Canadian health care systems than I'd like. The top-tier care in the US is indeed excellent for those who can afford it. Care in Canada is occasionally slow, often overcrowded, and has obvious gaps like dental coverage and pharmacare. But I would gladly take mediocre care that I know will always be there for me and everyone I love, over excellent care that I can only access because I can sign a big enough cheque.
Also, the private health services I have used in Canada are truly top-notch and far cheaper than in the US. They have to be, because they're competiting with a service that's available free to everyone.
I went in for a routine angiogram and was told "Your cardiac artery is very blocked. We're not sure if we'll let you go home tonight. You might need immediate surgery." But in the end, they did let me go home.
So then I was put onto the Waiting List. Some wait. Less than two weeks later, I was given a triple-bypass.
Out-of-pocket cost to me for a cardiac triple-bypass and six days in hospital, including 2 days in ICU, was ZERO.
The basic universal 'health system' aka very basic minimum health insurance mandatory by government solution is trash. It's true if you break your arm or need a flu shot they cover you.
If you have any expensive ailments you're going to be paying out of pocket. Cancer? My aunt was paying $10,000/month for chemo and that's like 1/3rd of her annual salary. Insanity.
Second tier you get a job your employer does give you health insurance. These are more often than not craptacular. 2 jobs ago the health insurance was that you had to pay 50% of the costs that they are being asked to pay. Most things weren't covered. No MRIs, nothing under that crappy health care.
Third tier my newer jobs, they were good. You had to pay 20% of most things but some things arent covered. You pay 100%. Current job is a bit better, public sector health insurance. You show that card and you pass lines. My coverage in the military let me jump lines like crazy. In the third tier you will only get a private hospital room if you are infectious.
The final tier are the people whose names are on plaques or wings in hospitals. Our hospitals basically dont function without rich people donating very large sums. Those people will jump any and all lines. They get private rooms. Rather nice large private rooms.
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[ 2.8 ms ] story [ 229 ms ] threadAmerican care is actually really quite good, but the cost curve is very aggressive, it's something like 2x as much and doesn't cover everyone.
And inverse is true: Canadians believe in some fantastically weird things about the US system.
In my experience as a Canadian living in the US, I was basically shocked at how new, modern and efficient everything was, how service was relatively quick and how knowledgeable the experts were.
The Canadian system 'covers everyone' but it absolutely rations care, you will wait quite a while for non essential services, and in some cases a little bit longer than comfortable for other services as well.
My concern about comparing the various systems, is that I believe a lot of the 'exceptionalism' of the US system bleeds out into the rest of the world and we benefit from that quite a lot.
The challenge is: how do we get the prices down without materially reducing quality of care because even as their gross inefficiencies, it's hard to suck out just the problem costs without affecting the system as a hole - akin to 'losing weight' if you go on a diet, you're going to lose muscle as well as fat.
An MRI might be “covered” but what if you have to spend 2 hours getting it approved beforehand and then 2 hours after proving that they said they’d cover it? Every time? For 4 MRIs?
I do agree that there should be a humanitarian component to it.
In Canada, it's the other extreme: everyone is treated identically (theoretically) no matter what and it's illegal to sell medical services in most cases. The way 'around' the problem is to hunt down good doctors through the network and word of mouth. Literally the Golf Club is where you find out who the best docs are, and then you apply with them and hope you have enough clout/status that they take you on as a patient, because otherwise you just get 'stand in line at the clinics'. Doctors have their own hierarchy/status, and you want one on the 'inside'.
What's more, most insurance is not generous. The insurer becomes the rationer of care by requiring value interventions before more expensive ones. Essentially any interest a state has in reducing costs an insurance company also already has. The main difference is that the insurance pool is probably healthier than the "everybody" pool.
Lastly, even if it is true America's system features better cutting edge medicine, I really doubt making the system less profit motivated would affect global health innovation. Perhaps a bit but quickly governments would realize they are going to have to invest in research more rather than purchase innovations from the U.S. This may actually increase the value proposition of research because there would no longer be a single locus drawing all competition for specialized labor.
Governments are not this sophisticated or operationally nimble unfortunately.
We're in a pandemic, and I watch our Provincial medical leaders come out and talk almost every day, they're all smart, but they don't really understand what is going on - they don't have the data. But in a pandemic that destroys 20% of GDP, maybe it would be a good idea to have every single person who takes a COVID test fill out a questionnaire, so the data can be made available? Masses of unemployed young people that could be put quickly and succinctly onto large-scale contract tracing programs? Releasing communications apps to collect data, getting national level experiments running to determine the primary vectors of propagation etc. etc..
They are all professionals with good intentions, but this does not remotely translate into operational effectiveness. What we need is a 'Dwight D. Eisenhower' kind of leader for this pandemic but his type is long gone and we may not even recognize operational efficiency.
Even during a pandemic when much is at stake, they're limited by their own systems. A much broader strategy of 'creating innovation to make up for the American loss' would't work, even throwing $ zillions at it wouldn't solve the problem.
The sophistication of Canadian products, and ironically economic diversity has been going down in Canada, as we focus on being 'really good' at being a good 'Foreign HQ' country.
My most recent hospital visit here in Quebec was a little scary: broken equipment in the main hall, the water fountain out of service, having to wait in a cold waiting room all day for a very small issue with no updates (and I couldn't even leave the room), the halls were lined with elderly people in beds because they were overcapacity. I did receive competent care, but the economic stresses were visible.
And of course I don't doubt for a second how insane the US system can be for billing, financialisations etc..
I think the US should be looking towards the Dutch or Swiss models, not Canada or UK.
As for unsophisticated but well intentioned provincials that is a problem here as well. My own uncle passed from a cancer which was diagnosed as non-aggressive by a rural for profit hospital yet later rediagnised as extremely aggressive at a more sophisticated facility 2 years later shortly before his death. Geography and demographics create provincialism, organizational structure obviously has an impact on how we respond to that difficult problem but regardless of if a healthcare system is for profit or not, a nation is simply not going to commit the same resources to rural areas.
To my mind, the more surprising thing isn't how different the problems of American and Canadian provincial care are but how much the same they are.
Regarding
> Governments are not this sophisticated or operationally nimble unfortunately.
I don't know that this is true. Governments collect and act on a lot of public health information.
As a Canadian I have no doubt that the US healthcare is better than Canada's in many ways… if you have the money to get that care. Or you're willing to go into debt to pay for it:
> Two-thirds of people who file for bankruptcy cite medical issues as a key contributor to their financial downfall.
* https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most...
However, Canada (and most of the Western countries) have lower infant mortality rates, lower maternal mortality rates, higher life expectancy, and a whole host of other health statistics. While often spending half on a per capita basis.
America has lower life expectancy because of violence, not healthcare.
That America has a cohort of poor people w/out care can easily drive a lot of the other numbers out of whack as well.
Finally, obesity, bad diet etc. - bad lifestyle choices are not a measure of the system either.
By and large, I view the American system as delivering better specific outcomes, without regard to price, all other things being equal.
Of course 'price' is a major factor as you indicate, and 'all other things' (diet, violence etc.) are not equal.
You may view the system as providing the best care for you, but that does not mean that the system is best in every sense?
It's like saying 'transportation' is one key to a healthy 'manufacturing system'.
If you are sick and you can have the choice between going to an American Hospital or a Canadian Hospital ... you go to the American one, because they are better, point blank.
But my impression is that is like saying that you are a better dad if you spend all your money on one of your kids' Harvard education and let the other one fend for himself or go into debt, when you could've given them both adequate education at a less expensive college?
My position is simply that a health ecosystem where everyone gets adequate care for free or at least without going into crippling debt is preferred over a system where some get lavish care and others none. It's not like there's a thousand people dying of perfectly treatable diseases due to queuing in the Canadian health care system - but there are indeed people dying because they can't access basic care in the American system.
By the way: When is transportation not a key to efficient manufacturing? Do you think that the efficient solution is for factories to make every single part of their product on site? Does it not matter whether spare parts for machinery can be ordered and delivered within 24 hours instead of 24 days? Or did you mean that what I said was obvious, i.e. the American health care system is clearly less efficient for providing solutions to the population than the Canadian, but you want to stress the point that it is possible, in some cases, to get better individual care in an American hospital?
> That America has a cohort of poor people w/out care can easily drive a lot of the other numbers out of whack as well.
Other countries help probably take better care of their poor with social programs, which would include healthcare (IMHO). See also higher taxes, which allows for redistribution of wealth and paying for said programs.
Opioid epidemic, violence, and healthcare system all play a role, both in life expectancy and quality of life.
> By and large, I view the American system as delivering better specific outcomes, without regard to price, all other things being equal.
What does this even mean? If it means choosing random encounters for equivalent similar conditions, and ignoring price, the outcome in the US is consistently or on-average better, I don't think that's true.
If you mean “where can the best care be acquired, without regard to how many people have access to it”, sure, that may be correct.
It means they have better Doctors, better processes, better equipment, more of it.
It means if you have a problem, and want to 'be fixed' - you would much prefer to be in an American hospital - the only question is 'can you afford it').
Rich Canadians go across the border to the US all the time for care.
Only 4% of US bankruptcies are because of medical bills (https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0...). A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect.
US is great if you are properly insured and if you are able to navigate the system. But also extremely expensive in comparison so the value for the money you spend isn’t all that good in comparison
Here in Germany we have public insurance and private insurance. If you have private insurance, you pay for health care yourself and then get the money back from the insurer later on. So you see what is actually being charged, and it is expensive.
If you are on public insurance, you never even see the bills. Often the private insurance actually has to pay for the public insurance, as health care businesses would be unable to survive without the extra money from the private insurance people.
Maybe if you see the bills because you are privately insured, they seem expensive. But perhaps they just reflect the actual real costs.
This means a greater share of GDP goes to pay for worse health outcomes. The cost of that lost GDP is measure in opportunity costs. That is GDP that could go to education, infrastructure, social programs or simply more savings for the median citizen.
It could be even worse, and a better health care system could make people be more careless about their health, because they would rely on being treated well enough to survive anyway.
Not saying any of that is the actual case, just that there are many aspects to consider.
As for controlling rent seeking behavior, wouldn't the insurance companies be interested in paying less? I don't see how private insurance facilitates uncontrolled rent seeking behavior?
It is very much a problem with public insurance, when patients never even see the bills.
In general, health insurance is a hard problem.
Regarding prices, yes insurance companies do negotiate prices to some extent but that has not controlled prices. See $20 asprin tablets given at many hospitals. There's a ton of reasons our private system has not done better controlling prices. It's hard to shop care. Insurers pass service costs onto employers who pay premiums who aren't consuming the care (the employee is). Medical companies find weird workarounds see medication couponing. I could go on. What it amounts to in the end is exactly rent seeking behavior, whatever the free market should be doing it is not. And there is no clear data that it is functioning more efficiently than a public system or at least a regulated market like Switzerland has.
In the end there's a reason that every developed country in the world other than America controls healthcare prices the same way. The government or a body backed by the government negotiates prices effectively fixing them.
Of course health insurance is a hard problem. No one ever said it wasn't.
yes...
I have what's called a "high deductible" plan, which means I pay 100% out of pocket until I rack up $1350 of medical bills in a calendar year. after that I only pay 10% until I hit a total of $2700. $2700 would not be catastrophic to my financial life, but it creates a moderate incentive to shop around on price.
Here in Germany, you get treated differently in some places if you have private insurance. I have actually avoided private insurance because I worried about too many unnecessary treatments (not sure if that was a good trade off - maybe if one day I'll get seriously ill, I'll regret that choice).
A bit annoying is that often the doctors won't even tell you that they are not suggesting a certain treatment because it wouldn't be covered by public insurance.
But what I mean is, possibly your treatment will somehow get cheaper once you are in the second stage of your insurance plan?
most health insurance plans make a distinction between "in network" and "out of network" providers. "in network" basically means your insurance has already negotiated favorable prices with that doctor. so the simple answer to your question is yes. if the doctor is "in network" they will probably charge you less than they would charge an "out of network" patient. if I go to an "in network" doctor but haven't used up my deductible yet, I still pay the "in network" price. if you get a very large bill, I suspect there is further negotiation that takes place behind the scenes.
> A bit annoying is that often the doctors won't even tell you that they are not suggesting a certain treatment because it wouldn't be covered by public insurance.
in my experience, US doctors usually treat the details of insurance coverage as the patient's responsibility. the doctor probably doesn't know exactly what is/isn't covered by your specific plan, so I doubt that they would change their recommendations based on your insurance. a good doctor will certainly be sensitive to the fact that costs matter, so they might let you know that a cheaper generic drug exists or suggest that you try a certain treatment first because it is cheaper.
aside from the cost, I don't think there's any downside to having private insurance in the US.
You may also be surprised what country contends with you for this place: Republic of India.
Some people say Gulf also has extensive private healthcare, but those forget that, I think, every Gulf country bankroll healthcare for their natives, and they do have near fully state funded hospitals. And yes, tons of Arabs in medical professions.
Most of "superelite" healthcare you see Gulf is just an extension of the medical market of the Subcontinent, and cater to nouveau riches to whom domestic market is not "elite enough" for their tastes.
That alone isn't sufficient. Germany is built on private insurance (on top of something similar to Canada's government insurance) and it works just flawlessly. Usually they pay everything, you don't need to do anything. You skip all lines at the doctor, can directly go to specialists without asking anyone, etc. And on top of that private insurance in Germany is considerably cheaper than government insurance, while providing like 10 times the benefits.
If I had to name one thing I really miss from Germany, it's private health insurance. This was just like being in heaven.
Why? Maybe private care is better than public care, i don't know, but insurance? Swisslife (one of the best/most efficient in my country) reimburse 65 to 67% of their anual income, so roughly 33% of what you're giving them goes into administration/coordination fees. Public insurance? 20% of the money they receive via taxes are used for administration/coordination.
So if i had a choice, i would pay a premium on public insurance (more taxes, or instead, asking my bosses to give the 120€/mo to the public insurance instead of paying swisslife). Better ROI.
The difference is profit motivation.
Germany does have private insurance, but there are regulations on what insurances companies can have margins on:
> As of 2020, salaried workers and employees who make less than €62,550 per year or €5,212.50[28] are automatically enrolled into one of currently around 105[29] public non-profit "sickness funds". The fund has a common rate for all members, and is paid for with joint employer-employee contributions. The employer pays half of the contribution, and the employee pays the other half.[30]
* https://en.wikipedia.org/wiki/Healthcare_in_Germany#Health_i...
Similar in Switzerland:
> Insurers are required to offer this basic insurance to everyone, regardless of age or medical condition. They are not allowed to make a profit off this basic insurance, but can on supplemental plans.[3]
* https://en.wikipedia.org/wiki/Healthcare_in_Switzerland
With US health insurance companies profit is job #1.
[citation needed]
Not at all. A significant portion of the government insurance is paid by the employer, so it ends up cheaper for the individuals. Also, children are included in the government insurance.
The prices you remember are for twentysome-year-olds without children.
In Canada, MRI machines were available only at a few major hospitals. It took months to wait to use one. In Chicago, where we were living at the time, she said it seemed as if there were an MRI machine on every block.
I think the situation is different now, but I think the observation is quite telling.
In my own anecdotal experiences (my own and from my friend circle) a lot of more chronic/non-urgent problems take forever to get looked at by a specialist in Canada.
Also, as personal experience, while living in Quebec, as I was in-between visa, I had to walk for 2 days on a broken foot as the ER wouldn't check me unless I paid ~1000$ for a consult. I was lucky to be be able to go to a private clinic, paid $50 and was done.
I really wish I could just pay to access a private practice...
In Ontario and out east I've never experienced anything remotely frustrating.
To the risk of being heavily downvoted: the NDP.
There are a lot of differences between BC and the other provinces. The NDP is only one fraction of those differences.
I am sure things are bad now because of the COVID-19 lock-downs, but I do not believe, ignoring the COVID-19 disruptions, quality of medical services are bad in BC or have gotten worse in the past three years.
Now try this in a private practice in the US and see if it costs only $50.
If you're not a citizen/landed immigrant/registered with a visa/etc anywhere in Canada you're going to see the raw costs of medical care for sure. You mention being in between visas. Depending on your accent and skin color you may have also experienced the systemic racism that exists in Canada that no one likes to admit exists.
At the end of the day, BC medical care works great if:
1) you can navigate and advocate yourself through the system 2) you have extended health coverage (usually through an employer but can be bought privately) 3) you have a doctor/nurse that can help connect you into the expedited route in the system 4) know when and how to access the secret private health industry (ie pay $700 for an MRI tomorrow instead of waiting for years for free ones) plus having the ability to pay for it.
I've seen this over and over. It's super charged squeaky wheel syndrome.
>I was lucky to be be able to go to a private clinic, paid $50 and was done.
I'm sorry, but can you expand on this? Did you go to an illegal clinic?
I'm from a middle-class family, but for reasons that aren't totally clear to me, my family didn't really have health insurance even though my father was employed. We were well-off enough that I was able to come to Canada for school, where I went to UBC.
These are the things I've experienced:
- You are required, as an international student, to sign up for the provincial healthcare program, MSP. I believe I paid $75 a month for health insurance.
- I was able to see a doctor very early on (mood disorder) and treatment was very satisfactory. I liked my doctor, I liked how the system works. Is it perfect? Of course not.
- I had an episode which put me in the hospital for over a month (would have been the start of 2016). At the time, I had not notified MSP of the change in my address, so I had stopped receiving bills and paying for them. When I was hospitalized, they told me that I owed about 3 years of MSP payments (around $3k). In essence, I paid 3k for a hospital stay that lasted close to 40 days.
- After being discharged from the hospital, I was assigned to a mental health team. It wasn't near where I lived, so I was able to transfer to a closer one. The team consisted of a psychiatrist and, in essence, a social worker who monitored my mental health and encouraged me to do things like group activities to make friends who were also dealing with mental health issues.
- As part of my hospitalization, I tried art therapy, which I continued to engage in after being discharged. Therapy was a bit expensive (think around $150 for an hour and a half, which was a bit much for someone who was just getting started working), but it was effective and helpful.
- I left the mental health team and began seeing a psychiatrist through UBC's student health services. I still see them even though I've graduated. I pay nothing for these appointments.
- I work full time and have private health insurance through my job. This insurance covers my current CBT costs for the most part, as well as providing an HSA plan which I use to pay for medication that isn't covered by MSP.
I've also done things like participated in a university study on perfectionism (12 weeks, group therapy situation).
I think the biggest takeaway from my experience is that, as a result of my mental health disabilities, I would not move back to the United States. I don't feel comfortable with the idea that healthcare would be tied to my employment. If I lost my job and was unable to adequately care for myself as a result, it would likely be close to impossible to find a new job!
To me, it feels like Canadian healthcare is not necessarily a perfect system, but it is a system which works well for most people. People aren't afraid of being sick, they're not afraid of medical bills causing bankruptcy, and they are more able to freely live their lives because the government is actually in a position to take care of its citizens.
The MSP was also eliminated this year, so now healthcare in BC is fully funded from general tax revenue.
https://bc.ctvnews.ca/b-c-is-the-province-with-the-lowest-he...
Other provinces in Canada have different but similar things.
I am absolutely happier having american healthcare than canadian. Admittedly, that's because I am of the 80 percent of people who get decent health coverage via my employer. A significant minority of Canadians agree with me, so it's not like this is some radical position.
There is a famous story in canada where you could get CT scans for your pet the same day, but non-urgent scans for humans had like an 8 month waiting list.
My great grandfather had to wait 6 months for cataract replacement. He considered going to North Dakota to have it done, as it was preventing him from working. So now canada has inadvertently fallen to the same trap as everywhere else: if you're wealthy enough you can just go to the us for care. Everyone else has to wait.
I've tried to say these sorts of views on reddit, but just get called a troll or a liar. I'm not trying to argue that public healthcare isnt better in some ways, or even that americans shouldn't consider it. It's just that these sorts of outlets tend to have a rosey view and give this impression that dissent arrises only from ignorance, and I must be some evil, Mr Burns-esque robber baron.
Just in this thread people are downvoting anyone praising the US system and talking about the shortcomings of the Canadian one. I've had a Canadian doctor tell me first hand that the US healthcare system is far superior provided you have insurance.
Speaking personally, I had surgery for a long-standing condition, which the surgery failed to correct. Under a different system, my issue might not have become chronic, I might have been able to make a better decision regarding the surgeon and surgery (e.g., getting a second opinion, follow-up imaging, etc.), and I would not have missed a follow-up appointment after losing my insurance. Because I'm an American, living under this system, the circumstances of my treatment and subsequent outcomes were drastically shifted towards unsatisfactory.
The US is at or very near the worst among OECD countries in: life expectancy at birth, healthy life expectancy, rate of obesity, disability-adjusted life years, doctors per 1000 people, deaths from treatable conditions, rate of mental health disorders, rate of drug abuse, rate of prescription drug use.
It would seem health insurance companies charge a lot of money for not such great healthcare.
Good healthcare is available to some in America, but not all healthcare in America is good.
> Its the insurance system that is broken.
Financing is the root cause of some of the other problems, but there are absolutely problems with care quality, too, even if resolving financing issues would lead to those going away.
Healthcare providers are not allowed to charge publicly-insured patients for covered services. Insurance companies are not allowed to insure for covered services. So for covered services (e.g. lab tests and doctor visits) the only available options is public. For non-covered services (e.g. ambulance, dental, prescription drugs, etc.) you pay out of pocket or use private insurance.
Many healthcare providers themselves are private. For example, doctors are independent contractors, not government employees, and their offices are private businesses. But they get paid for services by the government (why we call if a single-payer system rather than a public system).
B. It is not a loophole. The federal government fines provinces who don't rein in private billing. British Columbia loses millions of dollars in Canada Health Transfer every year because of lax enforcement though. BC lost $15.9 million in 2018 and was on track to lose $32 million in 2019, but they started enforcing the law better.
https://lop.parl.ca/sites/PublicWebsite/default/en_CA/Resear...?
https://www.cbc.ca/news/canada/british-columbia/extra-billin...
Also all those scans have been completely free.
The complaints I frequently hear from Americans regarding 'socialized healthcare' never ring true based on my experience in countries like the UK or Australia.
If you have good insurance in the US, you'll get a same-day CT in a hospital setting to bring in some revenue where a quick xray would suffice.
http://waittimes.alberta.ca/WaitTimeTrends.jsp?rcatID=19&rha...
https://www.hqontario.ca/System-Performance/Wait-Times-for-D...
The fact that 27 million people (1) live in the US without health insurance alone is a big enough reason to know that that US system is not working. People should not die or go bankrupt due to not having insurance.
The current system might work for the rich and privileged but that is not good enough.
1. https://www.census.gov/library/publications/2019/demo/p60-26...
They aren't; they are expressly included in GPs coverage statistics.
[0] https://www.youtube.com/watch?v=ceFyF9px20Y
Listening to NPR and their ilk would lead you to believe anyone else is some ignorant simpleton (the word 'deplorable' comes to mind)
That's 91-92% coverage of a country of 330 million.
91% of Americans have medical insurance, whether through their employers, or government programs like Medicare/Medicaid. That's compared to 95-97% in other developed countries because there are always some people who fall through cracks, like (say) a Canadian who doesn't get a new provincial health care card after moving, or a German who neglects to buy into a new sickness fund after changing careers. The only such systems with actual 100% (or as close to it as possible) coverage is something like the UK NHS, which does not have a requirement to show a membership card (because, well, there isn't one) to receive treatment.
PS - Obamacare did not greatly expand coverage. 85% of Americans had medical insurance pre-Obamacare.
There are things I'd certainly improve about the US system—decoupling primary healthcare coverage from employment, for one—but the way people online ~~lie~~ exaggerate it's not surprising that so many non-Americans believe that every American is one hangnail away from bankruptcy.
>People should not die or go bankrupt due to not having insurance.
Only 4% of US bankruptcies are because of medical bills (https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0...). A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect.
Have you ever thought about what would happen if you want to take 12 months off work so you can spend time with your kids, learn a language or just some personal time?
Have you looked into how quickly your insurance would drop you if you developed a serious illness, or suffered a major auto-crash with extremely expensive and life-altering medical conditions?
Tying ones health to their employment is barbaric, and as someone that has never suffered such a fate, I consider it the next step up from slavery.
i.e.
Slaves - work or you don't eat/live.
US heath insurance - work or you get bankruptingly-expensive healthcare.
(Rest of the developed world) - work or not, healthcare is for everyone.
I'm not really trying to argue one view or the other. I'm just saying that it isn't as clear cut as this NPR piece makes it out to be.
If you are lucky enough to have an employer that loves you so much that he/she is willing to pay ever increasing cost for your medical care, good for you. But I can tell you that you are in a tiny, tiny minority. As things currently, stand medical care costs are scary high and they are getting higher every year at a very scary rate. And most employers are looking at ways they can limit their health care costs, most of the solutions resulting in limiting benefits for employees.
Do you still have coverage if you get laid off? For how long? For kids too? That’s what freaks me out about the US system, is that it’s tied to employment to a high degree. This pandemic must have led to tons of people being laid off. Many of them got laid off and then they (or a family member) got Covid. How long after being laid off are people normally covered? How long is coverage for family members on the employee’s insurance after they are laid off?
I wouldn’t say care is better under my single payer than it is for US white collar employees, but I assign a massive value to the fact that I don’t worry about insurance or money if I get sick, have a child, or have a chronically ill child.
https://www.dol.gov/general/topic/health-plans/cobra
Yeah, no, that's not the same thing at all. As a Canadian I have health coverage I can, y'know, live with regardless of whether I'm employed or not. And buying coverage in the US (with a pre-existing condition) was absolutely not worth it (even considering the wage gap) when I entertained a few offers in the early oughts.
Staying here means I have substantially better freedom of movement and negotiating power. In the US the "freedom" to not have healthcare just seems to mean that everyone has the "freedom" to pay more - and often for less.
Are there other systems aside from Cobra that pick up where Cobra doesn’t? E.g for bankruptcy , companies smaller than 20 employees?
Even if it's the right thing to do, a lot of people are going to be opposed to it if it hurts them (even marginally). I think NPR sort of overlooks this, and focuses too much on the poorest 10 or 20 percent.
Certainly we need to care about the poor, but the rest of the people matter too.
Even if you have good insurance, wait times can be bad. For a point of reference, someone close to me had a potentially fatal condition and wasn't able to get a specialist appointment for 4 months. That sort of thing isn't uncommon.
I guess my gf will have to attempt suicide to get help then... maybe if she succeed, she won't be a burden on the system !
With the ACA, things are at least a little better than before: individual people can at least buy insurance, which wasn't the case before if you had a pre-existing condition and didn't live in a state with a subsidized program (like Oregon's OMIP).
A criticism I've heard of Canada's system is just that it's under-funded. They could raise their taxes a little and divert more money to health care, and it would improve some of these wait times. I don't know how true that is, though, and how much of a legitimate problem it is. Canada definitely pays far less per capita for health insurance than the U.S.
Seems 'unfair' to pay in for almost 30 years and have that count for nothing.
Fact Check:
Only 55.4% of all Americans and 58% of Americans under the age of 65 had employer-based health insurance in 2019.
https://www.census.gov/content/dam/Census/library/publicatio...
https://www.cbo.gov/system/files/2019-05/55085-HealthCoverag...
> I've tried to say these sorts of views on reddit, but just get called a troll or a liar.
I think it would help if you didn't start by saying that 80 percent of people have employer coverage, decent or otherwise. Because it's both false and easy to check.
I didn't mean it statistically, just that most americans are insured, either by purchasing privately or by their employer. It's an internet comment not a journal article.
Saying things you don't mean might be why people on reddit accused you of being a troll or a liar. I don't have proof, but it seems like a good place to start.
> It's an internet comment not a journal article.
"It's the internet so I can say whatever I want regardless of facts" is not a mindset conducive to meaningful conversation. I'm guessing again that it might be why the people on reddit dismissed you.
You might not think that this is important, but, speaking to your complaint that outlets "give this impression that dissent arrises only from ignorance, and I must be some evil, Mr Burns-esque robber baron", it seems pertinent that the available interpretations for people encountering what you said are that either you didn't know that the real number was far lower than what you said or you knew and were intentionally misrepresenting things.
Market rate in Mexico is undoubtedly lower than in the U.S., though. Speaking of Mexico, they seem to have a pretty solid public healthcare program. Maybe expectations are lower, maybe people are sufficiently contented by access to relatively unregulated pharmaceuticals and medical practices regardless of poorer outcomes, or maybe griping doesn't make it across the language barrier to American news, but it definitely seems like there's less anxiety about healthcare in Mexico.
As mentioned, dental coverage in the US is typically decoupled from medical coverage. (This is the same in Canada.) Your neighbors go to Mexico purely because most things, not just dental work, is cheaper there, as opposed to said dental work not being available immediately. Very different from why Canadians typically travel to the US for medical care, which is either a) to avoid long lines (and legislative prohibition of private clinics to pay more for quicker access), or b) expertise that isn't available in Canada.
Various Canadian politicians agree including Prime Minister Jean Chretien, who secretly traveled to the Mayo Clinic twice in 1999 (https://web.archive.org/web/20100204202553/http://www.montre...) during "ski trips" (https://web.archive.org/web/20160624132234/http://www.ezrale...).
If you aren't rich, you'll get care on par with developing nations. And our life expectancy reflects that. If you break down life expectancy by wealth, wealthy people in the Us live longer than wealthy people in most other places, but poor people fare far worse.
I hope we can find a system that maintains our exceptional outcomes while expanding who that applies to. I think the systems in France and Japan are pretty good. France has a public/private hybrid system and Japan has public insurance but also employer based insurance.
https://spendmenot.com/blog/medical-bankruptcy-statistics/
Medical bankruptcies represent 62% of all personal bankruptcies.
39% of those who have issues with medical bill payments already have employer insurance
I think you're right that if you have good insurance and you're wealthy you do ok, but it's easy to have employer medical insurance, have a serious illness, and have serious issues being able pay or expending a significant amount of personal wealth during that serious illness.
If Jeff stepped down today, he'd still be a billionaire, and besides he can just sell some stock first. He's probably already got a few 10s of millions just sitting around in cash "just in case"
The 62% number generally comes from: https://www.amjmed.com/article/S0002-9343%2809%2900404-5/pdf
Only 4% of US bankruptcies are because of medical bills (https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0...). A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect.
I don't live in the US, so I have no way of knowing what is the real experience.
https://twitter.com/wendellpotter/status/1276158510955401216
The justification for this company specifically is that paper payments need to move to digital and make it as efficient as possible because if not, someone else might get it wrong, and _they_ could make it even harder for Americans to get their finances processed in a timely manner. At the same time, digital payments and notifications makes it much easier to obscure who the point of contact should be when things go wrong and you want to make an appeal. Upwards of 80% of expenses for some healthcare transactions companies come from things related to paper checks, but I don't think anyone would point their finger at those fees and say "this is the reason why US healthcare is much more expensive than the rest of the world".
Especially during this pandemic, when we didn't want to dirty our hands further or deal with legacy healthcare IT code, we tossed it over the offshore wall in Taiwan and handed it to their armies of software contractors, some of whom even coming from India to live in Taiwan in order to have this opportunity.
The patients (called "consumers" or "members" in IT insurance parlance) are not actually the customer. The customer is the insurance companies like Aetna ("payers")
At some point you have to question if you want your career to be built on automating the rejection of millions of people and know that your code contributes to perpetuate current existing healthcare system in US. However, the thing is that the skills of a software engineer is becoming fairly routine and common, so unless you are something like Director of AI or Mr/Mrs. Design-Lead-for-Rare-Skillset, you are also fairly replaceable. Software engineers are told what tasks need automation, and they implement it. If not, hire a different one.
I'm also aware of and have lived under the Japanese healthcare system, and perhaps like the Canadian system, I know how much more reasonable it is despite the lesser amount of private access. It's also a myth that the US contributes far higher to medical R&D than the rest of the world, as Japan has close to the same proportion of R&D, yet Japan doesn't have nearly the same consumer costs as high as the US. Consider that ≈0.65% of American economic output (measured by GDP) goes toward healthcare R&D, while ≈0.40% of Canada’s economic output goes toward healthcare R&D, and Japan ≈0.50 (page 79) [1]. Every Japanese/Canadian citizen, on average, can afford to pay more proportion per capita on healthcare R&D than the US. Still, on some rankings, America ranks as one of the least efficient healthcare systems: 50 out of 55 on a Bloomberg index for developed nations [2]. The US has the highest healthcare spending, but does it at least have a return? Life expectancy says no [3]. Yes, it is arguable that life expectancy is too simple, but it is a simple way to intuitively compare healthcare system outcomes across different countries.
It makes me happy to know that Americans like Potter in the article are trying to find redemption for their past participation. I hope to find the same and find better ways to use my skills
[1] World Health Organization, World Health Statistics 2016: Monitoring Health for the SDGs Sustainable Development Goals. 2016: World Health Organization. bsanr2 ↗ >The patients (called "consumers" or "members" in IT insurance parlance) are not actually the customer. The customer is the insurance companies like Aetna ("payers")
This sounds frighteningly like the "overmind" theory of AI, wherein a system (perhaps the internet) becomes to higher order brain functions what they themselves became to the brain stem. The higher order systems pass currency (data, money) between themselves, over the heads of the lower order entities, making decisions that may or may not be in the latter's best interests (even though there is a clear hierarchy of existence that relies on the latter). Essentially, we've created a system where massive systems negotiate our life and death outside the public's purview and influence. Musk et al. warn about the dangers of AI, but with our existing systems, it seems that we're already there.
In my region, 5-6 hospital networks in 2000 have boiled down to 2 in 2020. Practices get gobbled up by the networks or form their own little cartels. For example, in my region a single nephrology practice controls 90% of the business in that speciality.
Still paid roughly $8000 out of pocket for a natural child birth and prenatal care.
It was so bad I took a full time job just for the insurance.
Doesn't that mean if you're in a massive car crash and require a ton of surgery and many months in hospital you'll essentially be bankrupt?
... what a terrible way to live.
I’ve contracted before and insurance is a nightmare. I stopped contracting and took a full time job because of it... even small startups often get terrible options because they’re not at the size to have any negotiating leverage.
Without a universal solution we’re kind of in a state of light indentured servitude. If it weren’t for healthcare costs I might not even work full-time... I’ve considered moving to canada just so I can be free from the burden.
I don’t think most Americans understand the mental weight of having to think about insurance at critical life junctures... even if you’re willing to disregard the millions of uninsured lives that fall by the wayside.
I have to think about premiums, copays, billing codes, in and out of network coverage, have awkward pricing conversations with doctors, call to fight denied claims... and sometimes I still get blindsided if for some reason lab work needs a second set of eyes (sometimes those eyes are in the same facility and out of network). Oh and for some reason my teeth aren’t covered as healthcare?
We’re boiled frogs with this stuff... people still think we have the best healthcare in the world but disregard the fact that it’s only available for the rich; we’re generally well out of the top 10 otherwise. I grew up in a rural area and I know multiple people who literally pulled out their own teeth because they didn’t have dental insurance. We need to start taking better care of each other.
Also, real cost would never go down until people realize that employers subsidizing outrageous premiums is never going to force the market to lower costs (mostly inflated due to insurance companies in the picture again for EVERYTHING).
I abandoned a financially successful independent contracting business of 15 years and went back to being an employee (ugh) because the Republican efforts to repeal the ACA freaked me out. I'm old enough that my wife and I both have some pre-existing non-chronic conditions, and I have a young daughter. Paying ~$20K of premiums annually for the privilege of having a $13K deductible was grudgingly acceptable to me. The uncertainty was not. The stress of wondering if insurance was going to be available year-to-year (in the final year I operated the business my County had exactly one marketplace plan available) was extreme.
I happened to get a job offer from a Customer. I decided that, though I swore I'd never be anybody's employee again, it was irresponsible in light of the efforts by the GOP to repeal the ACA to continue gambling that insurance would be available.
I had a taste of being uninsured in 2014 when, on pre-ACA grandfathered insurance, I had to pay out-of-pocket for treatment related to a pre-existing condition that wasn't covered. The idea of just how close we all are to a medically-induced bankruptcy really hit me at that point.
My quality of life is much worse now. I used to bill in 20 hours what I now have to report to the office "40 hours" to earn. I used to be able to spend more time with my family. I used to have the flexibility to make decisions about how and when I wanted to work, take time off, etc.
My Customers, some of whom I'd worked with for 10+ years, ended up stuck going with drastically more expensive (and less attentive and skilled) "managed services" companies to service their IT needs. The emails and calls that I get regularly asking for my help, along with the out-right statements to the fact, tell me that the situation for them isn't better either.
It's a racket.
My first appointment was in 2007 and there was such a concern that vets would be ignored the way they were after Vietnam that the pendulum swung the other way.
I’d typically not wait more than 48 hrs for an appointment, I had no copays, prescriptions/bloodwork covered 100%, physical therapy when I got injured, etc.
As a transitioned veteran in college with no insurance it was a dream.
Now that I have private insurance through work, I only keep it for my family, and I continue to use the VA for all of my healthcare.
It’s not perfect and wait times in places need to improve but for the most part, if you need help, you get it.
I had to wait almost a decade to get a family doctor.
Before I had a doctor, I had to wait 10+ hours in an emergency room whenever I needed a consultation or a prescription (which you need if you want to see a specialist). Now that I have a doctor, I can usually get an appointment with them within 1-2 months, and with a specialist within 6-12 months (after seeing my doctor). It guess it works if you're patient.
I once tried to get some vaccines before a trip to Asia. I called 2 public clinics and was told that I couldn't get a tetanus booster until 3 weeks later. I called a private clinic and they quoted me 3 x $200 for rabies (which was out of stock for a month) and 2 x $400 for Japanese encephalitis.
I decided to get them in Bangkok. I booked an appointment online, 2 days before arrival. I think I paid $100 in total for a tetanus shot, hepatitis A/B antibodies test, hepatitis B shot, Japanese encephalitis shots (2), rabies shots (2).
Of course, vision and dental are 100% out of pocket expenses.
I also find many drugs to be much cheaper in the US than in Canada. Some common drugs are 5x more expensive in Canada than in the US, when I look at GoodRx. The same seems to apply to blood tests.
However, I can't say I'm a fan of the US health care system. The obscenely inflated prices and the lack of price transparency puts those without insurance in a tough spot. I now wonder how COVID-19 affects those who rely on medical tourism for treatment.
Didn't you have access to walk-in clinics? They are everywhere and you rarely have to wait an hour to be seen by a doctor. Emergency rooms are intended for actual emergencies.
Source: living in Canada.
My mother in law is in a similar situation in the US. It costs thousands for a hospital stay with insurance. My wife has spent a few hours every month arguing with the insurance company.
Our retirement plans are in Canada. There is no way that we can afford to retire in the US.
Also, the private health services I have used in Canada are truly top-notch and far cheaper than in the US. They have to be, because they're competiting with a service that's available free to everyone.
Yeah, bullshit.
Single-payer public health system, Australia:
I went in for a routine angiogram and was told "Your cardiac artery is very blocked. We're not sure if we'll let you go home tonight. You might need immediate surgery." But in the end, they did let me go home.
So then I was put onto the Waiting List. Some wait. Less than two weeks later, I was given a triple-bypass.
Out-of-pocket cost to me for a cardiac triple-bypass and six days in hospital, including 2 days in ICU, was ZERO.
The basic universal 'health system' aka very basic minimum health insurance mandatory by government solution is trash. It's true if you break your arm or need a flu shot they cover you.
If you have any expensive ailments you're going to be paying out of pocket. Cancer? My aunt was paying $10,000/month for chemo and that's like 1/3rd of her annual salary. Insanity.
Second tier you get a job your employer does give you health insurance. These are more often than not craptacular. 2 jobs ago the health insurance was that you had to pay 50% of the costs that they are being asked to pay. Most things weren't covered. No MRIs, nothing under that crappy health care.
Third tier my newer jobs, they were good. You had to pay 20% of most things but some things arent covered. You pay 100%. Current job is a bit better, public sector health insurance. You show that card and you pass lines. My coverage in the military let me jump lines like crazy. In the third tier you will only get a private hospital room if you are infectious.
The final tier are the people whose names are on plaques or wings in hospitals. Our hospitals basically dont function without rich people donating very large sums. Those people will jump any and all lines. They get private rooms. Rather nice large private rooms.