pecunium | More on healthcare

More on healthcare

The Denver Post has a decent column up, Debunking Myths about Canadian Healthcare

There is also a forum for discussing it.

It's interesting, as one reads the comments (almost 450, at this count) to see the difference between those who think the US system needs to change, and those who don't.

Those who want to see it change cite studies, and polls. Those who don't cite opinion pieces, or make unspported statements (someone blamed Natasha Richardson's death on there being no helicopter; never mind that she refused treatment).

Most of the "rebuttals are things on the order of, "The US is best", and, "We don't want the beauraucrats making decisions". There are also the, "Gov't can't do anything right crowd."

When a Canadian opines (esp. those who have lived both places) that they like/prefer the Canadian system, they are called liars.

But my favorite comment was this one

I'm a Canadian, and I can tell you that we do have American-style care here in certain areas. I went to my medical provider when a member of my family broke a leg. I was astonished by the invoice for the operation: consultation fee, anaesthetic, bandages, various drugs, needles, assistance of three people, specialist- the invoice was three pages long. The total was nearly $1350.00. And I was very interested because I'd never seen a medical invoice before.

When another member of my family broke an arm, there were two operations, three casts, and twenty rehab visits without every seeing a single piece of paper.

Of course, the broken leg was my dog. The broken arm was my son.

You Americans treat your children the way we treat our dogs.

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I had a friend once with severe endometriosis. She was Canadian. She couldn't get the operation that she needed because it was elective. Finally, as a last-ditch effort, she came to the United States, got a job with health insurance benefits here, and got treated. She told me that it's very difficult to get any sort of "elective" surgery (such as those needed for pain management) in Canada.

However, my dentist was also from Canada and when he looked at my tonsils he commented to me that in Canada they would have taken them out a long time ago. As a (very) poor person I could never get a doctor/Medi-Cal to agree to remove them here.

So I think that people who unilaterally praise the Canadian system or pooh-pooh the American system aren't giving either system a fair shake. There are major problems with both, and neither is perfect.

FWIW I think the American system needs some significant work.

She told me that it's very difficult to get any sort of "elective" surgery (such as those needed for pain management) in Canada.

*tilts hand* Yes and no. The Provincial MSPs don't tend pay for elective surgeries, and they do in fact define "elective" as "you don't need it to survive/maintain your overall mobility". However, your own extended health insurance will cover what it covers. (As a secondary anecdata, I know more than one person who's quite easily gotten "elective" pain-management surgery, sometimes within weeks of the diagnosis.)

Medicare here is designed to cover all your life-or-death/public-health and fundamental prevention basics (doctor's visits, hospital stays, hit-by-a-bus scenarios, that sort of thing). Our private ensurers pick up the rest of the slack.

My low-income provincial MSP plan means that when I go to the doctor, I walk in the door and walk out again without paying a cent, and if I go to the emergency room I also don't pay a cent. My mother's extended (my being a dependent) means that I only pay half of my massage-therapy appointments.

Different purposes, different aims.

Edited 2009-07-29 04:15 (UTC)

I had something like your provincial MSP plan when I was on Medi-Cal and got supplemental free health care through my college. It was an unmitigated disaster, one full of incompetent morons who practiced the Occam's Razor method of health care - I can't tell you how many times I've been tested for strep throat, which I've never had. What I actually had were several bad bouts of bronchitis.

Of course the incompetency of particular moronic doctors have nothing whatsoever to do with health care plans and governments, excepting that here the morons end up treating the people who can't pay for anything better, while the people who can pay the most get the best doctors.

But, I didn't pay a cent for any of it. And I had no problem getting access to a doctor. To be clear I should point out that at no point in my life have I ever been one of those middle-class people who assume they're poor. I've been homeless 4 times (childhood and as an adult, not couch-surfing), I've lived without plumbing and electricity but under a roof, and I lived for some time in the desert in a home with plumbing and electricity but with no refrigerator. It's not actually hard to get access to a doctor, unless you break your leg 5 miles from the nearest road up a mountain (where I used to live when I was 6) and 20 miles past that to the nearest clinic. It is hard to pay the doctor's bills if you're not so broke that they write them off. That's what people are really talking about when they say that medical care is unaccessible.

But that was a tangent and had nothing to do with what you said.

My Canadian friend was too poor to afford private insurance. All she got was your Canadian Medicare life-or-death stuff. I think that what we refer to when we say we want government-subsidized health care is more like the health care that would enable a person to have an "elective" hysterectomy. Also, a lot of Americans live under the belief that Canadian health care is universal, that all of you could just run out and get Lasik surgery on your eyes if you really wanted to. As if any government system would cover that.

The New Zealand healthcare system could be a lot better but it's worth noting that my partner's father was just given "elective" weightloss (sort of) surgery that has dramatically extended both his life expectancy and his working years.

I would question your statement about accessability though, could you have gotten early screening for suspected cancer, or Glaucoma or any one of the number of medical conditions that are cheaper to treat early? Could you have filled prescriptions if they were needed? Could you have gotten regular treatment for chronic conditions like Asthma or diabetes?

One of my relatives is working on a genetic test for a particularly nasty chronic condition and I'm in the weird position of being happy that it will help with early treatment but vaguely horrified that it could be used to justify insurance companies refusing to treat people in the US.
How weird is it that advancing the cause of medical science could actually wind up hurting people?

I think what your partner's father got was awesome and I'm glad he got it. He must be relieved.

I think I'm an unusual case, though I had to be told by a friend that the program I'm on now for free health care existed. If I had not known about it, I would not currently be experiencing this free 6 month stint of health care. (IE I pay premiums but the HMO pays for everything I'd normally pay out of pocket.) I think that poor people who are proactive and resourceful and lucky enough to know about programs like the one I'm in are more likely to get good health care than folks with incomes. It's like our education system - I pay nothing whatsoever to go to University, but my boyfriend will have to pay because he's middle-class and makes more money.

Early screening for suspected cancer? I got that - but I got it because I asked. I found out that cancer runs rampant on my father's side of my family so I've been really proactive about that.

Glaucoma? Yeah, my vision tests are free and always have been. It's getting glasses that costs a fortune. In other words, it costs nothing to tell me my eyesight sucks, but it costs me $300 for a reasonable pair of glasses that won't break my nose under their weight or won't break if I sit on them. *sigh* Incidentally, my vision care insurance is so annoying that, despite my vision tests being free, I voluntarily opt to pay the cost of the vision test at the local Lenscrafters where I buy my decent frames.

Filled prescriptions? Currently my prescriptions are free. In March, before I filled out the paperwork, they cost me about $20/mo. My prescriptions are generic. I did have a prescription for Ambien, at $80/mo., which I couldn't afford - but Ambien is, to me, an optional drug. Now that my scrips are free, though, I might refill that one. Also, I have a friend who was so poor she lived in a trailer with an enormous hole in the livingroom (lounge) floor. She had a necessary prescription for Prilosec, which back then was horrendously expensive and non-generic, and she got it for free because she was indigent and there was no other appropriate medication for her at that time.

Regular treatment for chronic conditions like diabetes - hm. I don't have a chronic condition other than migraines right now, but my migraine treatments are free. But the little card in my wallet says that procedures and hospital visits are free and when I saw my doctor they said they'd bill the MFA plan instead of me, so I'm assuming that they'd be free. Not the lancets, though; you get those at the drug store. So, doctor treatments would be free, but routine daily blood tests would not. Though I've heard there's a program for indigent people to help them pay for their daily blood test equipment.

I think that it's absolutely unconscionable that anyone would use a genetic test to justify the refusal of treatment for sick people. I think we have a duty to care for one another at the very least because it's in our own self-interest, but also because I believe that people should make an effort to "love their neighbors." I hope your relative succeeds, and I hope that person's success isn't used to hurt anyone.

To add my anecdata to your anecdata, my former Toronto roommate had no problem getting OHIP (our provincial insurer) to pay for her endometriosis surgery. I had no problem getting a small Barthoman's cyst marsupialized. As in, we didn't have to petition anyone. Our respective doctors said something along the lines of "You need minor surgery to correct this. Here's how the surgery works. Call this person to see when we can do this." We each made our respective phone calls, showed up at the hospitals, had our surgery, went home, and went to our follow-up appointments without ever seeing an invoice or discussing the costs.

Both were elective procedures.

You do know that almost all surgeries are, "elective,"? It's a term of art.

Elective surgery: Surgery that is subject to choice (election). The choice may be made by the patient or doctor.

For example, the time when a surgical procedure is performed may be elective. The procedure is beneficial to the patient but does not need be done at a particular time.

As opposed to urgent or emergency surgery.

A liver translplant, a hip replacement, a boob-job and a coronary bypass, are all "elective".

An appendectomy, trepanning, or aneurysm repair isn't.

So while it may be the case she was delayed; and in pain, it's almost certainly not the case that she was flat out denied care.

I refer you to this comment for some comparative.

Go back and read the post that responds to, and tell me which system you'd prefer to live under?

This confuses me, as I'm a Canadian who had numerous elective surgeries. Platic surgeries, no less, for conditions that were cosmetic and didn't affect my functioning. So while I am not saying your friend's experiences didn't happen, in my own experience elective surgeries are accessible so long as a doctor believes they are medically indicated.

I can't assume that Canadian health care is the same everywhere you go. Is it? She lived on the east coast of Canada before she moved to the States.

My friend had no supplemental private insurance. She was unable to get a hysterectomy in Canada in the 1990s. She came to the US and got her hysterectomy around 2000. Perhaps things were different then, or now?

I'm guessing her Canadian doctor didn't think the hysterectomy was medically indicated. He wanted to manage her symptoms with Lupron, which will set a woman's body into an artificial state of menopause. This is considered a radical treatment, sort of the last-ditch effort, for endometriosis prior to hysterectomy. He was unwilling to contemplate surgery and she was unwilling to keep living with the horrendous side effects of the Lupron. So she moved.

The other factor in my case is that I was under the age of 10, and the surgeries were to correct birth defects.

The thing about your friend's treatment is that it seems based on factors other than money. Otherwise she would have been told, "I am recommending you get X treatment, but it will cost you." However, many doctors are very reluctant to perform hysterectomies on women of childbearing age, and unfortunately if you can't get a doctor to prescribe that kind of treatment, you can't get it funded.

Yeah, hysterectomies are touchy that way. It took me years of argument and stress just to find a doctor that would tie my tubes, a procedure that is potentially reversible. I even had one doctor tell me that tube-tying caused 80% of women who underwent such a procedure such terrible pain afterward that most of them required hysterectomy to resolve it. Obviously he was lying.

Her treatment issues had nothing to do with money. I also had a hysterectomy for the same reason and mine cost me $50 from start to finish. It's a lot more about access, I think, than money.

I have no idea how Canadian doctors talk to each other. If her first doctor said he would not perform the hysterectomy, would that go into a file or something that other doctors would see and then refuse to perform the surgery too?

I dislike the idea of some non-doctor deciding if a procedure is necessary or not based on cost-versus-benefit analysis. I don't believe that healthcare, or education (for that matter), should be treated in any sort of profit-making way. I think that treating every human endeavor as if it were a business that folks should receive profit from is a little inhuman. On the other hand, I equally dislike the idea that a person with a medically-verifiable problem could be refused a treatment shown to resolve the problem because her doctor had emotional problems with the procedure.

Yeah, my mom had to suffer through five years of endometriosis before she finally got into menopause. The problem in this case was that doctors didn't diagnose it. She could have had her whole apparatus out - she was well over fifty and had a daughter already - and saved herself quite a bit of pain.

It can't possibly be.

in alberta, if you and your doctor "elect" to do a hysterectomy because of endemetriosis, all you're paying for is your cable tv and telephone in the hospital.

It might be a difference between "have" and "have not" provinces - the atlantic provinces are not that wealthy, and newfoundland was even less so in the time period you describe, whereas alberta is extremely wealthy and so has a lot of money to include in a health care budget. my provincial health care includes Chiropractic visits and Physical Therapy, and I know that's not included for every province.

I can't assume that Canadian health care is the same everywhere you go.

Basic rules set by the Federal government, actual programs run by the provinces according to their abilities, political and local degree of being Alberta (Most provinces score very low Alberta levels but there's a big spike out on the prairies).

The canadian system is not rosy, agreed. Though you should know that what is covered in public healthcare coverage varies from province to province. Your friend might have gotten the short end of the stick on this one.

That is a most excellent comment.

I didn't say so last time, but I am with you completely on this. I grew up with military health care. It worked. Now, as a woman in my forties who's had cancer (never mind it was a rare form with a 15% mortality rate), I live in complete dread of the day my COBRA runs out or I can't pay the $400/month anymore.

We need this, and we need it now. I know too many people living without insurance or living on COBRA and struggling to pay for it. This is not acceptable.

Military health care works for some, not for others. BTDT but I haven't been able to tease out the variables to determine why the VA and active duty care is far more variable than the U.S. norm.

Variable in cost or effectiveness, or something? I'd be curious to hear what you do find.

Agreed, I'm not saying it was perfect. But military doctors saved my life when I was four, they saved my brother's hearing, and care was always available.

It's mostly an issue of budget, locale, and client load. LA has lots of vets, so things are crowded.

Wadsworth is right next to UCLA, so it has good residents, but that meant I was seeing a new one every time I did a periodic (though the overseeing rheumatologist never changed).

Palo Alto is next to Stanford, I expect them to be much the same. Sepulveda (in LA) isn't next to a med school, so the specialists are (so I am told) handled differently.

The VA is also funded inconsitently. Under Bush is was a bit starved. Obama seems to have moved money around, and he put Shinseki in charge (which was a thumb in the eye to Bush), and Shinseki cares (I'd follow him pretty much anywhere, so I may be biased, but the bias is because he cares).

My memories are a bit fuzzy, and I was mostly healthy growing up. But I'm fairly certain it was a military doctor who preventing me dying of pneumonia (this was in New York). Same with my brother's ears, in Hawaii. And I know my sister and I were both delivered by a Navy doctor, also in New York.

It drove me absolutely crazy to hear the Bush administration shout "Support the troops!" when we also heard about how consistently underfunded things were.

Some of the places we lived were too small to have military hospitals, so we saw regular doctors. I don't think my parents had to pay for it though. I should ask.

Hang on. When I was 18 and we were moving in a motor home from Juneau to New Orleans, I passed out at Wall Drug Store. I was taken in an ambulance to an Air Force hospital somewhere near Mount Rushmore, which was not a short drive, and somewhere in the haze of pain and narcotics I remember they did this because paying for the ambulance was cheaper than taking me to the emergency room elsewhere.

I have no idea what hospitals they have in Wall, South Dakota, and maybe the level of care was part of the consideration too. But I will definitely ask.

Nothing makes me happier than not being a dependent of the military. The substandard care. The waits. It was a disaster. Horrible. It didn't work at all. Nor does it work for vet friends of mine, or vet family members.

We need something, but I wouldn't hold military care as what to aspire to. Not with people I know who suffered from it.

Whereas I have never had any problems with it. Efficient, thorough, attentive.

The only problem I ever had was a poor practitioner (dentist) and I never saw him again (becsause one can refuse). But optical, top notch. Internal medicine, top notch.

Related care, top notch. VA has been good to me too.

I am really sorry you've had such bad experiences. I'm not saying we all need military care, I'm saying that we need to have a system where the inability to pay doesn't equal inability to get health care.

That comment is absolutely awesome!

We need to see those invoices, though.

My son, who is disabled, gets medicaid and private insurance.

Medicaid pays shit, and I never see anything from them. Not what they paid, not who, not how much.

HOWEVER, private insurance pays first. So they send me a statement of benefits.

That is how I found out that the government got completely and totally ripped off for a piece of his medical equipment, what a disgusting scam it was.

Because of this company charging quite a bit as much for this equipment, is probably the reason we can't upgrade as soon as he needs it. Because of thieves like them.

If I got this piece o shit broken device myself, online, it would have been under 2k. The bill to my insurance company? Eight grand. They got me a laminating machine (about $200 on amazon) and boardmaker software ($400). They also charged $800 IN ADDITION to try it out for a month. So nearly 9k on a piece of crap that doesn't work, isn't appropriate (they did not show me any alternatives, I had no idea there were any), and was overpriced.

By the way, the expensive 'extended waranty and support' meant that I had to pay an additional few hundred dollars when stuff on it broke. Now, it is completely broken. They looked at it and said "it isnt charged", and handed it back. It was. UGH.

If medicaid just paid, we wouldn't need to see the invoices. We have to see them because it isn't all covered.

I never saw an invoice for military care, they just ordered it. I don't see invoices for VA care. When I needed a brace, they wrote the prescription, I went to orthotics, they fitted it, and I left.

Same day service, not a thing for me to sign.

Then who would see that a company is ripping off the (government/insurance company) for so much? I spoke with the company that makes the device and they said that the charges that my insurance company made were completely unreasonable. So did the specialists at the clinic we go to once a year, as did his local therapists. Everyone was suprised that they got away with charging so much, but since it isn't often that someone uses such a thing, the research isn't always done. Costs are out of control. Because of that, my son cannot get another device although he sorely needs one, because of thieves like the people who sold us the first device.

Plus if people see invoices, they can tell if they are padded, if they charged for procedures that never happened, and so on. Is it ok for you if you found out they charged for two braces and a week of inpatient therapy if you never got it?

I don't need to see those invoices. The auditor does, but I don't.

I don't care, directly, if they listed extra treatment/equipment, because the fraud won't affect me directly (if there is fraud). Part of how such frauds work is because most people can't spot it. I was billed for drugs I didn't get when I had my kidney stone. I doubt it was itentional. I protested it, because I had to pay. If I didn't have to pay then the drugs they forget to chart will probably balance the accidental extras.

If there was a single insurer, then the ability to pull a shuck and jive (if only one person in a year, in a market; per insurer, uses a thing, there is no way to easily compare it) is a lot less, because all the charges will be going to the same, "company".

It's part of the economy of scale.

I see no reason why people should not be a part of their care, part of what is happening, and involved in that. I want to see what is being billed, what my treatment is, what is going on. I want transparency. Maybe because in the grand scheme of things you're better off than my son, and can be lax like that, but when you have costs like we do, you want to keep an eye on who you are working with and how they operate. I'm not about to write a blank check. It will only hurt me and my children down the road. Why medicaid does not do an EOB is beyond me. So wasteful, if you ask me. We're talking thousands and thousands for this one issue alone. And I think if people are aware of costs, they'd be more careful of what they do, at least some people, and would question as a whole why things are the way they are.

I am involved in my treatment. Invoices aren't about treatment, they are about payment.

If the bill is paid, you don't have costs. That's the whole point of the people I know who live in Britain and Canada. They don't pay a cent for needed care.

They have insurance for drugs, and dental and optical, but that has nothing to do with what the billing for things like

iclysdale's kidney replacement, or my mass of tests to make sure I didn't have a bronchial infection not a drug reaction.

If I'd had to pay for them (or worry that my insurer might deny them) it would have been different.

But it was completely transparent. The doctors made suggestions, we talked about risks, benefits, probabilties, methods (the worst for anxiety was the spinal tap, the riskiest was the pulmonary biopsies, the most lasting were the punch biopsies).

As for the "blank check", it doesn't apply. Unless you know the charges are out of line, how can you prevent it? Insurers are good at spotting blatant fraud. They pay professionals to do that.

We shouldn't have to.

I'm receiving Medicaid, and the particular program I'm on now sends me a regular statement, outlining the charges made to my account, and whether and how much each item was covered.

Personally I prefer my health insurer telling overbilling hospitals where they get off instead of having to do it myself... especially as it tends to take ages to clean this up if you do not have a lawyer on retainer, and in the meantime the bill gathers interest, threats are made and collection agencies are involved.

Even with an insurer, it's a huge pain.

Friend of mine has two insurers. One of them is the first billed. He has a regular treatment. Routinely (as in for years,at this point) the provider will bill the wrong insurer first.

They deny, and the provider bills him because of it.

Then the provider refuses to bill the actual company (in this case Medicare) which is supposed to pay.

Every time.

I'm in Germany with mandatory insurance, so the doctor cannot bill me unless I agreed before the start of the treatment and in writing. Everything else is between the doctor and the insurer.

My mother has optional insurance (she's not in any of the "mandatory" categories) and we have folders full of paperwork for her, both for the standard processes and when the insurance didn't "get" that 200 kg of lead are not an ortheopedic aid, or the hospital sent the bill to the wrong address, or any such fun.

I knew there was a reason as to why I chose to not have children.
No,wait! My veterinarian treats my cats better than most doctors I've been to in my life.

Now I'm confused.

It might have to do with knowing you can afford to pay for it, out of hand, and so being worried about you leaving for a better bedside manner.

There are also issues with the training of, "the omniscient presence".

One of the interesting things about having been assigned an intern, was seeing someone with most of the basic knowledge, and none of the years of practice. If he kept the attidude (which I encouraged... being a Staff Sergeant had a lot wieght with a liuetenant; the moreso because I was an educated, and informed patient) he was going to be a great doctor; one whom the patient trusted.

Zing!

Here's a good column, from a Canadian (right-wing) newspaper, debunking American myths about Canadian healthcare:

http://www.ottawasun.com/comment/columnists/lisa_vandusen/2009/07/29/10295956-sun.html

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