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Saturday, August 1, 2009

My Personal Perspective on Canadian Health Care

Robert has asked for my perspective on some of the comments being thrown around about Canada's health care as the American government continues to debate health care reform. As I am rather busy right now, I have not had a chance to do any proper statistical research, so my response here will be motivated by personal experience and anecdotes (in defense of my personal anecdotes, I have lived at various times in my life in two provinces in Canada (British Columbia and Ontario) as well as four years in the United States (Pennsylvania). While I recognize that such experience is not equal to statistics and other forms of hard fact, it can at least help explain where some of my perspectives come from). I have numbered and put in quotation marks the remarks Robert picked out of the media and sent me, and then written my responses beneath them.

1.) "In Canada, if you are old, but have a treatable illness, the government will deem you not worth the investment in health care dollars, and will let you die."
- I really have no idea where this claim comes from. I would have to see some pretty strong evidence showing age-based discrimination for treatment in Canada. I have a number of well-aged relatives (my mother's side of the family seems particularly robust), and I have never known any of them to be refused treatment. As one example, almost fifteen years ago, my grandfather (a retired school superintendent) suffered a rather devastating heart-attack. He was flown to Vancouver and operated on, resulting in a quintuple bypass that saved his life. I think that disproving this claim, though, is rather difficult, as it depends a lot on definitions (such as what is old, what the treatments being talked about are, and so forth). This is one of those fear-mongering statements that is slippery enough to retreat under scrutiny rather than admitted incorrect.

2.) "In Canada, if you have cancer, you have to wait 6 months or more before getting a bed to be treated, time that will of course cause the cancer to spread and kill you."
- Once again, I am not sure what this claim is based on. For one thing, many cancers don't require a hospital bed for treatment (or, if they do, it is on a rotating basis... you need to spend a couple nights in the hospital every few months). There is also no set time course for treatments (treatment once again depending on the cancer and its stage), but everyone I have known has had treatment options proposed as soon as cancer is diagnosed. Some of those treatments might be delayed somewhat due to the availability of facilities (such as surgery or imaging equipment), but I doubt it would be in a manner which would seriously endanger one's health without some unforeseen circumstance (such as a miss-diagnosis as to the cancer's initial severity or aggression).

3.) "In Canada, you cannot see whichever doctor you would like to."
- Well, neither can you in the States... doctors have finite amounts of time and resources, just like all parts of the medical system. There are systems in place for requesting a new doctor or a consultation visit, however. This actually factors in to the availability of medical resources in Canada in general, which I am going to talk about at the end of this post.

4.) "In Canada, you cannot choose your treatment option."
- A ridiculously worded statement... I'm not even sure what it means. In the United States you cannot choose whatever treatment you desire, either. When multiple treatments are available, Canadian doctors usually outline them and go over the various advantages and disadvantages between them. Of course, some doctors have personal biases which might influence their decisions, and not all doctors are good at communicating available options to their patients. Rather than a national thing, I think the number of treatment options one ends up with is more dependent on the individual doctor and the given ailment. Also, many treatment options are not always a good thing. While it gives the patient a better sense of control, I would rather doctors ignored dubious treatments (particularly things like "alternative medicine"). If there is only one treatment option supported by evidence, then there is only one treatment option I want my doctor giving me.

5.) "In Canada, a government bureaucrat stands between you and your doctor, and that bureaucrat often determines that you do not need the health care that your doctor prescribes you."
- Much like the first claim, this is a misleadingly slippery statement. How often is often? It is not as though every medical decision needs to be approved by a bureaucrat. There are oversight committees to ensure that doctors are not making uncalled for treatments, but for the most part the doctors prescribe what they feel is necessary. In general, I believe, bureaucrats design general guidelines for healthcare practice (and determine the allocation of funds for equipment and other health facilities), but within that framework doctors are relatively free to act (it is not like every treatment decision must be scrutinized and approved). In many ways, having the "government bureaucrat between you and your doctor" makes things run more smoothly, since the doctor is aware beforehand what resources are available for treatment and there is little worry of finding out later that it is not covered (which is the situation with having a private bureaucrat between you and your doctor). Whenever I have dealt with the more privatized forms of health care (while living in the States and with dental care in Canada), I have found it much more confusing and bureaucratic. Every insurance group has their own sets of policies and coverage plans, so there is often a great deal of confusion as to how payment should be made and what will be reimbursed. When there is a private insurer, it is in their interest to not cover as much as possible, and thus there is always a bureaucrat involved in treatment decisions.

6.) "In Canada (this claim was actually made on the floor of our House of Representatives...sorry about this) 1 out of 5 people DIE because of the health care system."
- Of all the claims being thrown around, this one confuses me the most. What the hell does it mean for a person to die because of the health care system? In order for such a statement to be supported, one would have to be very careful about defining what it means to die from a health care system. As Colbert pointed out, five out of five people die... 20% of deaths being caused by our health care system seems just plain ridiculous. To make such a claim, I imagine it would have to be a fairly loose set of rules for assigning blame, and so I would be interested in what proportion of deaths in the United States were caused by the American health care system under that same definition of blame.

7.) "The Canadian government will only allow so many operations per year. Once this figure is reached, they will stop paying for them."
- This seems like a horribly twisted statement. There are a finite number of surgeons in Canada, and thus they can perform a finite number of surgeries every year. The government pays the salaries of those surgeons, so yes, the government pays for a finite number of surgeries each year. However, it's not as though, if somehow surgeons across the country started finishing operations extra fast and thus reached a set number of surgeries by mid-October, the government would say, "No more surgeries!" and the surgeons would all go and have a nice two and a half month vacation (at least, this would be news to me). Also, this statement suffers from the same ludicrous vacuity as the cancer statement. Not every surgery is equal in either time or resource requirements, making this statement not only obtuse and twisted, but also overly simplistic.

8.) "Because of the socialized nature of the health care, in Canada, people do not innovate, and Canada's health care is not as advanced as America's."
- This statement is stupid in so many ways... for one thing, our two countries do a lot of intellectual sharing. Also, innovation is done for more than just profit, and other than theoretical science I don't think that is more true anywhere than in medicine. People are motivated to innovate for prestige, for the betterment of society, and simply for the joy of solving a difficult problem. For an example of not only intellectual sharing but also innovation not motivated by profit, insulin was first isolated as a treatment for diabetes at the University of Toronto by Banting and Best, who then sold the patent for a dollar to the university as they trusted it to disseminate the treatment for the betterment of humanity rather than for monetary gain. As a result, insulin is a widely available treatment around the world (yes, this is a fairly old treatment, but it did not require research on my part). Finally, the "socialized nature" of our health system does not completely remove monetary rewards, although it does possibly diminish the factor that they play (something which I think can easily be argued to be a good thing).

Finally, Robert asked me a few questions of his own:
"Those are some specific claims. What is your impression of the Canadian health system? Do you like it? Have any horror stories? Do you pay 60 percent in taxes to get that health care?"

If it hasn't become clear from my responses, yes, I do like our health system. I think it is a decent system which does a good job of providing care for as many people as possible. This does not always translate to the flashiest care or even the fastest (and no one likes to wait several hours in the emergency room, but that happens in the States too). I cannot really think of any horror stories, but perhaps people reading this will chime in. This has actually gone on longer than I intended, so I just want to make one last point about the Canadian health care system. Canada is a large and sparsely populated country. While we do have regions of fairly dense population (like southern Ontario), a lot of the country is decidedly not dense. This makes providing specialized health care very difficult for certain things. My grandmother, for example, has Parkinson's disease. While she has a general practitioner in my hometown, getting specialized advice from a neurologist is more of a challenge. The nearest center larger than my hometown is about an hour and a half drive away, but even that town only has a population of 20,000-30,000 people (depending on how you define the town boundaries, like always). Thus, to get a consultation, my grandmother has two main choices: go to Calgary (a six hour drive) to see one of the neurologists there, or wait for a traveling neurologist to come through the area (I think the traveling neurologist is still a two hour drive away, but that is closer than six). Going to Calgary provides the most flexibility in appointment times, but six hours is a long drive. Seeing the traveling neurologist generally leads to the long wait times that are so often touted as failings of our system in the U.S. Really, though, many of those long wait times are actually caused by our geography and population distribution. Likewise (from question 3), assuming the drive to Calgary was impossible for my family to execute, my grandmother would only have the option of seeing the traveling neurologist, and in that way she would not have the option of picking her doctor. But once again, that is not a direct outcome of our medical system, but is actually a result of our geography. In a similarly isolated region in the United States, it would not make individual economic sense for a specialist to go there, so she might not have any option.

Anyway, like I said, this got a lot longer than I intended, but it is an issue I feel strongly about. While Canada is certainly not perfect (health care is expensive, and we do therefore have perpetual budgetary issues and a certain level of unpleasant bureaucracy), I think the maligning that takes place is overly simplistic, disingenuous, ignorant, and rhetorical fear mongering. Perhaps when I get more time I will go and dig up some proper statistics on the matter, but I encourage others to look into these things as well. If you feel I have made mistakes, left anything out, or would otherwise like to add something, be sure to let me know.

P.S. I realise I did not answer the tax question... long story short, I pay very little tax as a student. I'm sure my dad, who actually makes a decent amount of money, has a different impression of the tax situation in our country, but I don't want to put words in his mouth. I have a lot of thoughts on taxes, but those are for another time.


G said...

Cheers! Bureaucracy has almost nothing to do with the practice of health care in Canada. As is said, the government distributes the funds: individual physicians make decisions as to treatment. Wait times are an ephemeral concept. Many people now have joint replacements: is the wait time from the moment the specialist says " this will need doing" or from the time he/she says "now is the time to do this". If the former the wait may be two years, if the latter it is a matter of days or weeks: and hip replacement is not life threatening.
Robert did not even ask about the cost. I am the person who had the heart operation: immediately before that I had a femoral artery by-pass. I spent roughly six weeks in hospital: operations, intensive care units, etc. I emerged and didn't pay one cent for any of the treatment. Fourteen years later, I have my health and my money. I am happy to pay taxes for such treatment. And the taxes do not amount to the percentage of my tax dollar mentioned. Something strikes me as extremely ludicrous when the mention of the word "socialist" changes a nation of 340 million people into a mass of unthinking blogs.

Robert said...

This is excellent, thank you for doing this! One thing I hardly ever hear from is a Canadian perspective on health care, so I did enjoy reading this.

I had formulated answers to these questions (or, rather statements) in my head before i sent them to you, and I was glad to see that we largely lined up in our answers.

I kid you not, this is getting insane, Obama is starting to have to answer questions about whether or not his health care plan will kill old people (because that is how they do it in Canada, so the questions go). Frankly, if I was the Canadian ambassador, I would file a formal compliant with the Republican party, and the various national news media in this country, complaining of defamation of national character or something. I mean, you people up there may say "about" in a hilarious and different way, but you are not unfeeling backward savages, which is how I feel like the Republican party makes you out to be.

A quick ER horror story for you. And I am well insured by my father currently (but I will lose my insurance in about 10 months). I have bad knees. Rather, they walk just fine, but any excessive running (particularly down hill) or jumping and twisting, and they are easy to dislocate. It is the worst pain I have ever been in. Anyway, the last time I dislocated my knee (I have done this multiple times) I was in the emergency room for an hour and a half before even a nurse saw me. She then told me she would be right back with some pain pills. 2 hours later she returned. Then, about 30 minutes to an hour after that, I saw a doctor would took xrays and such, then fitted me with a straight leg brace. This entire time though, I was in the waiting room crying in pain.

Of course, this is not necessarily an indictment of our health care system. I just happened to get hurt on a busy day at a busy time. Two summers ago when I broke both my arms, I went into the ER, they took my vitals and then immediately sent me back and I saw a doctor within about 10 minutes (though, with the pain meds and xrays and such I was in there for about 3 hours, though was being treated that entire time). This however was probably because when I walked into the ER on that day, there was exactly one other person in the waiting room.

Finally, I will say this. Living in America with out media system can be tough. Because good information is just so rare. And even I, single payer leftist, find myself fighting knee jerk reactions to believe the fear mongering promoted by the media. These claims are just repeated so often, and taken for granted even, that when you are immersed in this stuff, it almost becomes instinctual for a person (me) to buy into or believe the claims. I have to actually do work and take time to think through them to catch myself from accepting bullshit. Maybe that can be another blog post at some put, if it fits in with neuroscience, how hearing claims over and over again, even if you know they are wrong to begin with, can slowly grind you down so that you actually have to think hard to convince yourself that the claims that you know not to be true, are in fact not true. Anyway, in my own personal internal struggle, this post helps.

Mozglubov said...

Glad I could help. Sometimes I do wish that our government could somehow lodge a complaint, but I'm not sure anyone would listen. Plus, I'm not sure they would try right now, since we have the Conservatives in power right now...

As for the repetition of "facts" making them harder to dismiss, that is definitely a problem (and something political parties figured out a while ago, hence answering with the talking points regardless of what question a candidate was asked). There are a couple psychological properties that I think impact that, so perhaps I will remember to do a post on it once things calm down a bit here. I always like getting post ideas!

Kim said...

A humorous, fact-based dissection of a few claims against Canadian health care is here:

Regarding taxes, I think the highest personal tax bracket is just over 50%, so I'm not sure how anyone could come up with a 60%+ figure for health care...

Patrick said...

Thank you Calden. As an American who knows better, I apologize for both generalizations - to compare Canadian Health Care as an example for ObamaCare and to the "Don't let this happen to you" Poster Child characterizations.

ObamaCare's "cherry picking" of talking points features does not help the argument nor does it come close to what the Canadian system really. Where the Canadian System has evolved to address the diverse needs of Canada's topography. It is the evolutionary template of change than should characterize Canadian Health Care and not the superficial generalization of "single payer." (Talk about throwing away the baby with the bath water.)

At the same time "Choice" is two sided sword. If we choose to live on top of a mountain, we should have lowered expectation of snow plowing or garbage collection.

If we eat, drink or smoke excessively, if we neglect our health, we lower our options. If we throw caution to the wind and live a riskier lifestyle, we reduce our health options. The choices people make cannot be distilled to a lowest common denominator entitlement by bureaucracy at a lowest possible price point.

Oddly, with all the arguments I have seen which attempted to compare the US and Canadian systems, I am shocked at the most glaring contradiction of differences. Canadian Health Care is less expensive and that Canadian's are less likely to take legal action in malpractice.

The threat of tort action turns out to be a far greater expense in the US than the actual litigation. Here the threat includes the cost of insurance as well as the added procedures that may be ordered "just in case" or "just to see for sure."

We are therefore not just treating the ailment, we're trying to early detect too. The patient that turns out to be positive is a great success story and the system provided that patient with cost effective health care.

For the negative resulting patients, these extra procedures/tests have elevated the cost of health care for everyone - both the positive patients as well as everyone who will never be treated for even the symptoms.

Leave it to a left or right eyed politician to mandate closing the other eye to complete making their point/argument. Shame on all who don't keep both eyes open or fail to think about what they see.

Jackelyn said...

Glad to see intelligent discussion on this from people from all different systems. I'm not able to articulate much of what Calden did, so I'm glad to see this post and resulting comments.

Anonymous said...

First, I acknowledge that every system has its bad and good points. I also will acknowledge that each person opinion is based on their experience. But I can not accept that the Canadian system is as good or even better then ours. I know some people in Calgary, and I talked to one recently. He needed an hernia surgery, and was initially told that he would have to wait until the end of September (the conversation was in June) for the surgery. He was later contacted and was told that if he could drop everything and come in a the end of June he could be operated on then, because someone canceled. He and another Canadian on the phone both were surprised that they someone would cancel, given the how long they would have to wait again to get the surgery. Fortunately for him, he had a job where he could drop everything for a few weeks for the surgery and recovery. I had a hernia surgery here in Richmond, VA a few years back and was able to get it scheduled in less than a month.

Geds said...

Wow, Freddy. That one story really changed my mind about everything. I was being horribly misled about Canadian healthcare by, y'know, Canadians. But one story from a guy who knows one guy who managed to get a surgery for a non-life-threatening condition moved up from the horrible future time of September to the immediate future (well, past, now) time of June has caused me to completely change my opinion of everything.

Thanks for letting me know how much of a pain in the ass Canadian medicine is. I guess we should stick with the American system where only people with good jobs and/or lots of money get to actually have their problems treated and everyone else can go rot and die somewhere.

Oh, and the World Health Organization rates Canada's system as the 30th best in the world. America's is 38th. So you don't have to acknowledge anything.

Mozglubov said...


I am not sure why you claim to acknowledge both the good and bad points of different systems as well as personal experience motivated opinions, only to then flat out claim, "But I can not accept that the Canadian system is as good or even better then [sic] ours." Why not? I assume that ease of scheduling a hernia surgery is not the sole metric by which you measure a health system.

Of course, this is beside the point, as my post is not equipped the make the argument that the Canadian health care system is better or worse than the American (even if I believe it is... to make a proper claim, I would need to more carefully define my metric and have actual statistics). All I was trying to do was make the point that the actual claims being made by politicians and journalists (or commentators, as some of them claim to be in order to avoid the unpleasant task of fact checking) are misleading and disingenuous at best on even a superficial level of examination. While you may think that my perspective on health care is flawed, I still do not think you should dismiss the possibility that Canada has a better health care system based on a single anecdote.

Anonymous said...

The first part of my message was basically acknowledging that no system was perfect, and we can keep pointing to the bad cases as a reason to make a change.
I then pointed to a bad example that I was aware of in Canada, from personnel contacts, for contrast. Of course you have no reason to believe that story, anymore then I have to believe you Mozglubov (I am not calling you a lair, I do not know you and thus can not make that claim) as we do not know each other and can not verify each other identity. All we have to point to is what each of us posted. This inability to verify each other is a fact of the web.
Ged, you mentioned the WHO report that shows Canada has a better health care system then us. Reports like that have to be taken with a grain of salt, and really can only be used to judge changes overtime, but not make direct comparisons. The main reason for this is that the data used to make that report is self reporting and there is no standards set on what data is used to answer the question. For example the US treats all infants that are delivered alive, but then die as a infant death. Other countries say if the infant dies in the first 24 hours it is a still born. We also tend to detect cancer earlier, which increase survival rates. Whereas other countries tend to detect it later, and fewer survive. Basically those report claim to be comparing apples to apples, but they are really comparing apples to oranges.
Finally my belief that our system if better, but not perfect, comes from what the system it is based on. All my reading of history, philosophy, and economics show me that a system not based on free markets is doomed to fail. I know a lot of people in this country point to the failures of the free market in this country. The problem is that while we have a freer market then most, our markets are not really free. Whenever we have problems in our markets you can trace it back to government involvement. It is for that major reason that when offered the choice of our current system and it current level of government involvement and a system with more government involvement, I will choose the current system. If you offered me a system that had less government control of health care, I would support it whole heartily. I am not being offered that option, so I oppose what is being offered.
I have posted even more on what I believe the problems are with health care and health care reform on my blog in the following entries. Read it if you want.

Mozglubov said...

Freddy, I know this is a late response so I don't know if you are still around, but I've put up a recent post regarding your comments (or you can directly just go to my friend's post on market failures).

cornucrapia said...

this is a pretty good example of the problems I have with privatized health care from a theoretical perspective