If America adopts Canada's health care system

[mariomike]

I have paid for EMS in both AB and ON, which is fine because I could afford it, and I understand the reasoning.

As you likely know pbi, in Ontario, ambulance service is billed at a rate of $240.00, of which all but $45.00 is covered by provincial health insurance.

Patients can claim the $45.00 on their private insurance.

Persons receiving benefits under the Ontario Works Act, the Ontario Disability Support Program Act or the Family Benefits Act or provincial social assistance (general welfare assistance or family benefits) are not billed.

Cheers

 

[Cbbmtt]

In B.C. ambulance service is not covered, that's one of the selling points to my job as we provide those benefits.

Ambulance is around $100 in B.C. and an Air Lift is approximately $1000.

I believe very low income also do not pay for these services.

 

[Infanteer]

Amb in BC is $500.  Had to pay it before.

 

[Cbbmtt]

Amb in BC is $500.  Had to pay it before.

Non-MSP Beneficiaries: All the above Ambulance Transport Categories

persons with no valid BC Care Card (e.g. visitors to BC/non-residents, as well as work related injuries, claims under RCMP, and other federal agencies).

$530 flat fee (ground service)
$2,746 per hour (helicopter)
$7 per statute mile (air plane)

I was talking about if you are a B.C. Resident, it's $80 bucks.

 

[Bruce Monkhouse]

...and if someone really, really needs an ambulance then that is cheap.

 

[observor 69]

Heard in ER " Can I get the ambulance to drive me home?"

 

[Edward Campbell]

My favourite system is Singapore's: everyone is covered, no one gets "catastrophic" medical bills, but nothing is free. Here, from the government's web site is an outline of it:
_________________________
Singapore Healthcare System

Our Philosophy

    The Ministry of Health believes in ensuring quality and affordable basic medical services for all.

    At the same time, the Ministry promotes healthy living and preventive health programmes as well as maintains high standards of living, clean water and hygiene to achieve better health for all.

Structure and Budget

    Singapore’s healthcare system is designed to ensure that everyone has access to different levels of healthcare in a timely, cost-effective and seamless manner.

Healthcare Services and Facilities

    Healthcare services are accessible through a wide network of primary, acute and step-down care providers. More

Healthcare Regulation

    The Ministry of Health and its statutory boards regulate both the public and private providers of healthcare in Singapore. More

Quality and Innovation

    To ensure that patients are treated safely with good healthcare standards, the Ministry strives to promote better quality and innovation through various initiatives. More
_________________________

Singapore has a universal healthcare system (as we do in Canada) within which affordability of care is ensured through a system of compulsory savings, subsidies and price controls. It uses a combination of compulsory savings from payroll deductions to provide subsidies within a nationalized health insurance plan known as Medisave. Within Medisave, each citizen accumulates funds that are individually tracked, and such unds can be pooled within and across an entire extended family. Most Singaporeans have substantial savings in this scheme. A level of subsidy is chosen by the patient at the time of each healthcare action.

A key principle of Singapore's national health scheme is that no medical service is provided free of charge, not even within the public healthcare system. This mechanism is intended to control the demand for healthcare ~ uncontrolled demand is almost always seen in fully subsidised universal health insurance systems. Out-of-pocket charges vary considerably for each service and level of subsidy. For the wealthy, although each out-of-pocket expense is typically small, costs can accumulate and become substantial for patients and families. For the poor, the subsidy is in effect nonexistent, and patients are treated like private patients, even within the public system.

I have seen the system as reasonably close range and I am mightily impressed with the quality of healthcare, overall, for ordinary, working class, Singaporeans. The rich - and there are a good many rich Singaporeans - can care for themselves, just as they can anywhere in the world. That the rich, including the very rich, get their medical care in Singapore rather than going to e.g. London or Los Angeles, suggests that care is of the best quality. What is impressive is that the working class folks are treated by the same doctors in the same hospitals with, I am told, the same care and concern. Maybe the working class don't get private suites and gourmet meals, but that not why they we go to the hospital, is it?

Walter Russell Mead looks at Singapores system in this post which is reproduced under the Fair Dealing provisions of the Copyright Act from his blog viaMeadia:

http://blogs.the-american-interest.com/wrm/2013/08/28/singapore-where-affordable-care-is-a-reality/

Singapore: Where Affordable Care is a Reality

August 28, 2013

Efficient health care tied to affordable cost, high quality, and universal access is possible, at least if you’re a country called Singapore. In April, Brookings Press published Affordable Excellence, the first “comprehensive system-level description” of the Singaporean health care system. Tyler Cowen is in Singapore this week, and he’s written a few posts on its health care, pivoting off of the Brookings book and his own conversations in the country:

    Yes, the system really is a marvel, and no it is not laissez-faire.  The mix of “private money, public provision” has some marvelous properties for economizing on costs, not the least of which is that private hospitals
    and doctors and medical device salesmen do not become too strong a lobby.  And the level of conscientiousness in Singapore is high enough that the public hospitals work fine, though they don’t in general have the
    luxuries of the private hospitals.  Furthermore those public hospitals have to compete against each other for patient loyalty and thus revenue, and so the reliance on private money helps discipline public hospitals [...]
    In any case let’s start by admitting, and keeping on the table, the notion that the current version of the Singapore system is indeed a poster child of some sort.

One thing that’s not clear to us from what we’ve read so far is if and how Singapore’s system facilitates innovation. We simply cannot solve the global health care crisis without innovations in medical technology and service delivery.

Nevertheless, we do get this feeling that the tone of the debate since Obamacare’s rollout has stagnated. Singapore shows us that there are all sorts of interesting models out there that defy the easy categories of our own domestic discussion. Singapore’s system shifts a lot of costs onto the consumer directly, but it also has single payer for catastrophic insurance and lots of public provision of care. It combines these things that libertarians and conservatives generally like—see this 2012 guest piece talking Singapore up by Avik Roy—with targeted government intervention that goes beyond what American conservatives are generally comfortable with.

With the very important caveat that America is a very different place than a small Asian city-state, or even a medium-sized European country, studying how other countries have gone about solving these problems is probably a very good idea.

One model Americans need not examine is Canada's, we, like them, spend too much and get too little for our money in terms of "outcomes."

Equally, Canadians, must stop fixating on American health care ~ there are, indeed, lessons to be learned there but they are, by and large, related to what not to do.

As to medical innovation: there is lots in America, but there is lots, too, in e.g. : Canada, the Czech Republic, Britain, South Africa, Germany, France and Singapore. The issues is to share knowledge and, for a country like Canada, to follow a model that works ... ours doesn't; America's doesn't; Singapore's does.

 

[dapaterson]

An interesting article from a year ago suggests that The Cheesecake Factory may be the model the US health care system should emulate.

http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande

 

[Colin Parkinson]

I always get tired of the either or argument. I have seen the Malaysian Health care system up close and have a sister inlaw deeply involved in policy making in it's regards. A useful model to look to.

Healthcare in Malaysia is mainly under the responsibility of the government's Ministry of Health. Malaysia generally has an efficient and widespread system of health care, operating a two-tier health care system consisting of both a government-run universal healthcare system and a co-existing private healthcare system. Infant mortality rate – a standard in determining the overall efficiency of healthcare – in 2005 was 10, comparing favourably with the United States and western Europe. Life expectancy at birth in 2005 was 74 years

http://en.wikipedia.org/wiki/Healthcare_in_Malaysia

 

[a_majoor]

Well plenty of people have said "told you so", but DBD lays out the cause and effect in a very compact form. Notice the consequences of government intruding even farther in an already dysfunctional system: 300,000 people dumped from their coverage, premiums rising rapidly (even doubling) for most people (that is, people who were even able to get on the system....) and intrusive busybodies "acting in the bset interests of applicants assisted" (they are working for someone's best interest, but it isn't the customer buying insurance....)

http://www.daybydaycartoon.com/2013/10/27/

 

[a_majoor]

More on the US healthcare mess. Apparently only 6 people were able to navagate their way through the website and actually purchase insurance (vs 300,000 who got their insurance cancelled in Florida alone). Don't worry, the person responsible has a new plan!

 

[a_majoor]

WSJ nails it, and in the process outlines a plan that would work well for Canada as well. Like our cousins to the south, we spend an inordinate amount of money for a very poor outcome. This proposal brings back the element of competition and market forces to control costs and prioritize resources, the only thing missing is transparency in how tings are priced (i.e. you not only know how much you pay for insurance, but also how much the doctor or hospital is going to charge you before you decide to fork over insurance or deductable money).

http://online.wsj.com/news/articles/SB10001424052702304439804579208020624280740

How the GOP Should Fix ObamaCare
Along the way Republicans can create real choice, real competition and real savings while protecting those who need help.

By HOLMAN W. JENKINS, JR.
Nov. 19, 2013 7:27 p.m. ET
Republicans are the only ones who can fix President Obama's broken promise now.

The problem is simply stated. Millions will be losing their individual insurance policies that they were promised they could keep. They will be expected to buy more expensive ObamaCare-approved policies than they want or need, and to do so from ObamaCare exchanges that aren't working.

Mr. Obama's fix, which he proposed on Thursday and which was quickly debunked by the insurance industry and its state regulators, can't work because Mr. Obama can't let it work. He has to fight to preserve the central purpose of ObamaCare—to use the individual mandate and ObamaCare's compulsory benefit list to capture money from unwilling buyers of ObamaCare's gold-plated insurance policies to subsidize others.

Let's understand: The stumbling block to fixing Mr. Obama's broken promise is Democrats clinging to the central redistributive scheme embedded in ObamaCare. There is no reconciling the two.

Americans are beginning to understand that the essence of the Affordable Care Act is that millions of people are being conscripted to buy overpriced insurance they would never choose for themselves in order to afford Mr. Obama monies to spend on the poor and those who are medically uninsurable due to pre-existing conditions. Both Mr. Obama and Republicans are blowing smoke in claiming that the damage done to the individual market by the forced cancellation of "substandard" plans (i.e., those that don't meet the purposes of ObamaCare) can somehow be reversed at this point. It can't be.

What can be done is Congress creating a new option in the form of a national health insurance charter under which insurers could design new low-cost policies free of mandated benefits imposed by ObamaCare and the 50 states that many of those losing their individual policies today surely would find attractive.

What's the first thing the new nationally chartered insurers would do? Rush out cheap, high-deductible policies, allaying some of the resentment that the ObamaCare mandate provokes among the young, healthy and footloose affluent.

These folks could buy the minimalist coverage that (for various reasons) makes sense for them. They wouldn't be forced to buy excessive coverage they don't need to subsidize the old and sick.

If this idea sounds familiar, it was proposed right here three years ago, after the 2010 elections in which Democrats lost the House due to public disquiet over ObamaCare.

Because such a move could be sold as expanding the options under ObamaCare and lessening the burden of an unpopular mandate, it always had potential to draw Democratic support. That's doubly true now that Democrats are saddled with President Obama's promise that anybody who liked their existing insurance can keep it. Mr. Obama's promise is not literally keepable but the national charter would be the next best thing, letting millions find policies that are a good deal for them in their particular circumstances.

And, yes, this would also blow up the disingenuous financial engine of ObamaCare. This is a feature not a bug.

The ObamaCare exchanges would devolve into refuges for those who are medically uninsurable. But this seems increasingly likely to happen anyway. The federal government, having assumed the job of subsidizing these people, should do so honestly and openly.

ObamaCare is dead on the vine. It becomes clearer by the day the only way insurers can make the Obama benefits package work at a monthly premium affordable by healthy people who don't qualify for subsidies is with massive deductibles and copays and narrower provider networks. ObamaCare's individual mandate, as philosophically odious as some find it, would survive. An admirable principle buried in ObamaCare—that subsidies should be reserved for the needy—would also survive.

What wouldn't survive is the Democratic scheme to force everyone, regardless of age and actuarial risk, to buy a gold-plated package of benefits that will stimulate a wasteful race to spend more resources on health care. And, down the road, by reforming ObamaCare, much else could be reformed, including Medicare and the ill-begotten and destructive link between employment and health care.

This outcome will shock liberals who have single-payer sugar plums dancing in their head right now. Let's leave them with one thought.

The government-run systems you so admire in other countries mostly came about long ago. They came about to expand access to medical care at a time when medical care couldn't do all that much for people. We live in a different age. America, let's face it, would be embarking on a single-payer system not to expand access—though that slogan would be used—but to deny and limit care in order to control runaway spending.

Liberals, you think you want to go there but you don't.

 

[a_majoor]

As more and more details bacome apparent to the American people (things that commentators identified would happen long ago BTW), the idea of "Potempkin websites and "onions of fail" begin to take root. This article identifies some of the root issues with why Obamacare will fail (there are other articles that ignore the structural failures here and focus on the transactive failure: young people are refusing to sign up for overpriced "Healthcare" to subsidize the sick and poor). What is interesting is Obamacare induces the same failures we already experience in Canadian healthcare into the already expensive American system:

http://www.the-american-interest.com/blog/2013/12/10/aca-increases-deductibles-by-42-percent/

ACA FAIL FRACTAL

The Deeper You Get, The More Dysfunction You See
Deductible shock is here. The WSJ reports that many Americans will experience serious deductible increases as the Affordable Care Act plans go into effect:

The average individual deductible for what is called a bronze plan on the exchange—the lowest-priced coverage—is $5,081 a year, according to a new report on insurance offerings in 34 of the 36 states that rely on the federally run online marketplace.

That is 42% higher than the average deductible of $3,589 for an individually purchased plan in 2013 before much of the federal law took effect, according to HealthPocket Inc., a company that compares health-insurance plans for consumers. A deductible is the annual amount people must spend on health care before their insurer starts making payments.

Higher deductibles can, in certain contexts, be useful for introducing some price sensitivity into the system. But that depends on how people go about dealing with them. There are two deep-rooted problems with what remains in many ways an excellent health care system overall: it is too expensive, and not enough people have enough access to it. The cheaper health care becomes, the easier it is to expand access. In a cheaper system, fewer people need subsidies and the subsidies they do need are smaller. Without fixing costs, on the other hand, more and more people, not to mention the government, struggle to pay for our system, and the resources for expanding access shrink as the cost of do so grows.

Unfortunately, the Affordable Care Act puts most of its effort on the wrong end of the problem: access rather than price. That’s one reason the rollout has been going so poorly and in some respects will get worse. Because not much effort was put into cost control, many insurers have taken the one easy step available to them to limit rate shock: restricting provider networks. As a result, people are unexpectedly losing access to doctors they have seen for years.

A reform that put cost first, on the other hand, would recognize that high deductible plans need to be paired with other cost-saving measures, like wider use of nurse practitioners and better policy for retail chains operating as McDoc shops. Many lower-income people would be better able to afford care in that kind of system, and those who couldn’t would be subsidized at a lower cost to the rest of us. And, finally, more of the cost of routine care could be shifted onto the consumer while

 

[a_majoor]

While the WSJ is making an observation about the American heath care market, virtually all of the observations apply in spades to our own dysfunctional system as well, and adopting policies like this would deliver a massive shock to the ossified current system and break barriers that stifle competition. With health care consuming 40% or more of provincial budgets, this is really the only way to go:

http://online.wsj.com/news/article_email/SB10001424052702304866904579265932490593594-lMyQjAxMTAzMDIwNjEyNDYyWj?cb=logged0.8838936918363806

What to Do When ObamaCare Unravels

Health insurance should be individual, portable across jobs, states and providers, and lifelong and renewable.

By JOHN H. COCHRANE
Dec. 25, 2013 3:51 p.m. ET

The unraveling of the Affordable Care Act presents a historic opportunity for change. Its proponents call it "settled law," but as Prohibition taught us, not even a constitutional amendment is settled law—if it is dysfunctional enough, and if Americans can see a clear alternative.

This fall's website fiasco and policy cancellations are only the beginning. Next spring the individual mandate is likely to unravel when we see how sick the people are who signed up on exchanges, and if our government really is going to penalize voters for not buying health insurance. The employer mandate and "accountable care organizations" will take their turns in the news. There will be scandals. There will be fraud. This will go on for years.

Yet opponents should not sit back and revel in dysfunction. The Affordable Care Act was enacted in response to genuine problems. Without a clear alternative, we will simply patch more, subsidize more, and ignore frauds and scandals, as we do in Medicare and other programs.

There is an alternative. A much freer market in health care and health insurance can work, can deliver high quality, technically innovative care at much lower cost, and solve the pathologies of the pre-existing system.

The U.S. health-care market is dysfunctional. Obscure prices and $500 Band-Aids are legendary. The reason is simple: Health care and health insurance are strongly protected from competition. There are explicit barriers to entry, for example the laws in many states that require a "certificate of need" before one can build a new hospital. Regulatory compliance costs, approvals, nonprofit status, restrictions on foreign doctors and nurses, limits on medical residencies, and many more barriers keep prices up and competitors out. Hospitals whose main clients are uncompetitive insurers and the government cannot innovate and provide efficient cash service.

We need to permit the Southwest Airlines, LUV -1.00%  Wal-Mart, WMT +0.10% Amazon.com AMZN -1.56%  and Apples of the world to bring to health care the same dramatic improvements in price, quality, variety, technology and efficiency that they brought to air travel, retail and electronics. We'll know we are there when prices are on hospital websites, cash customers get discounts, and new hospitals and insurers swamp your inbox with attractive offers and great service.

The Affordable Care Act bets instead that more regulation, price controls, effectiveness panels, and "accountable care" organizations will force efficiency, innovation, quality and service from the top down. Has this ever worked? Did we get smartphones by government pressure on the 1960s AT&T T +0.06%  phone monopoly? Did effectiveness panels force United Airlines and American Airlines to cut costs, and push TWA and Pan Am out of business? Did the post office invent FedEx, FDX +0.09%  UPS and email? How about public schools or the last 20 or more health-care "cost control" ideas?

Only deregulation can unleash competition. And only disruptive competition, where new businesses drive out old ones, will bring efficiency, lower costs and innovation.

Health insurance should be individual, portable across jobs, states and providers; lifelong and guaranteed-renewable, meaning you have the right to continue with no unexpected increase in premiums if you get sick. Insurance should protect wealth against large, unforeseen, necessary expenses, rather than be a wildly inefficient payment plan for routine expenses.

People want to buy this insurance, and companies want to sell it. It would be far cheaper, and would solve the pre-existing conditions problem. We do not have such health insurance only because it was regulated out of existence. Businesses cannot establish or contribute to portable individual policies, or employees would have to pay taxes. So businesses only offer group plans. Knowing they will abandon individual insurance when they get a job, and without cross-state portability, there is little reason for young people to invest in lifelong, portable health insurance. Mandated coverage, pressure against full risk rating, and a dysfunctional cash market did the rest.

Rather than a mandate for employer-based groups, we should transition to fully individual-based health insurance. Allow national individual insurance offered and sold to anyone, anywhere, without the tangled mess of state mandates and regulations. Allow employers to contribute to individual insurance at least on an even basis with group plans. Current group plans can convert to individual plans, at once or as people leave. Since all members in a group convert, there is no adverse selection of sicker people.

ObamaCare defenders say we must suffer the dysfunction and patch the law, because there is no alternative. They are wrong. On Nov. 2, for example, New York Times NYT -0.39%  columnist Nicholas Kristof wrote movingly about his friend who lost employer-based insurance and died of colon cancer. Mr. Kristof concluded, "This is why we need Obamacare." No, this is why we need individual, portable, guaranteed-renewable, inexpensive, catastrophic-coverage insurance.

On Nov. 15, MIT's Jonathan Gruber, an ObamaCare architect, argued on Realclearpolitics that "we currently have a highly discriminatory system where if you're sick, if you've been sick or you're going to get sick, you cannot get health insurance." We do. He concluded that the Affordable Care Act is "the only way to end that discriminatory system." It is not.

On Dec. 3, President Obama himself said that "the only alternative that Obamacare's critics have, is, well, let's just go back to the status quo." Not so.

What about the homeless guy who has a heart attack? Yes, there must be private and government-provided charity care for the very poor. What if people don't get enough checkups? Send them vouchers. To solve these problems we do not need a federal takeover of health care and insurance for you, me, and every American.

No other country has a free health market, you may object. The rest of the world is closer to single payer, and spends less.

Sure. We can have a single government-run airline too. We can ban FedEx and UPS, and have a single-payer post office. We can have government-run telephones and TV. Thirty years ago every other country had all of these, and worthies said that markets couldn't work for travel, package delivery, the "natural monopoly" of telephones and TV. Until we tried it. That the rest of the world spends less just shows how dysfunctional our current system is, not how a free market would work.

While economically straightforward, liberalization is always politically hard. Innovation and cost reduction require new businesses to displace familiar, well-connected incumbents. Protected businesses spawn "good jobs" for protected workers, dues for their unions, easy lives for their managers, political support for their regulators and politicians, and cushy jobs for health-policy wonks. Protection from competition allows private insurance to cross-subsidize Medicare, Medicaid, and emergency rooms.

But it can happen. The first step is, the American public must understand that there is an alternative. Stand up and demand it.

Mr. Cochrane is a professor of finance at the University of Chicago Booth School of Business, a senior fellow of the Hoover institution, and an adjunct scholar of the Cato institute.

As to why Obamacare is so totally dysfunctional; you need to understand it has nothing to do with "healthcare" and everything to do with forced intergenerational transfers of wealth (healthy young people subsidizing sick and older people's insurance) and control over a large portion of the American economy  by political crony capitalists. In those respects it should work quite well (except that young people see through the scam and are not signing up on the "exchanges").

 

[a_majoor]

Interesting observation from Bloomberg, costs have actually been falling across the English speaking world since 2005, and the rest of the developed world as well. Given the dramatic differences in how systems are organized, it is difficult to determine why this should be happening, although the spread of technology, and in particular communications and IT technologies may have something to do with this (new procedures and discoveries can pass through the medical community much faster than before, allowing for better and more cost effective treatments to spread rapidly). As the author points out, there can also be negative factors leading to cost reductions, so it is important to identify what is actually going on.

http://www.bloombergview.com/articles/2014-07-17/obamacare-isn-t-what-s-slowing-costs

Obamacare Isn't What's Slowing Costs
JUL 17, 2014 5:25 PM EDT
By Megan McArdle

Health-care cost growth is slowing, and the Congressional Budget Office expects this to continue. Is this good news?

To many people, that question may seem crazy. Every other week seems to bring another lurid graph showing that if you project out health-care costs for the next 40 years, 100 percent of our income will be devoted to hip implants and cardiac stents. What’s not to like about slower growth in a major expenditure?

Well, much depends on why it’s slowing. If health-care cost growth is slowing down because we’re working a lot of inefficiency out of the system, then the slowdown is obviously a big win for everyone except health-care providers and their shareholders. This explanation is a big favorite with the Barack Obama administration, which likes to credit the Affordable Care Act and related policies for the slowdown.

But health-care cost growth might be slowing down for other reasons. Innovation might be slowing down, in which case we’ve got good news and bad news. The good news is that we’ll be spending less on health care in the future. The bad news is that we won’t be getting so much in the way of new treatments.

Or the slowdown in cost growth might reflect broader growth trends in the economy. In that case, I’ve mostly got bad news: Health-care cost growth will be slower in the future. But so will economic growth. Health-care spending will be lower in the future, but so will revenue, meaning that we’ll be poorer -- and we’ll still have a problem with the budget deficit. So this is pretty much lose-lose.

Which of these three things is the case?

Well, I think we can be pretty sure that public policy is not making the system more efficient, for two reasons. First, the decline started in the middle of the last decade, and there’s no plausible policy mechanism that would have caused cost growth to moderate just then. And second, the same broad trend shows up in pretty much every high-income country. No matter how smashing you think Obamacare was, it didn’t stabilize health-care spending in Switzerland.

It could be a matter of better practices in the industry. One piece of evidence for this: The cost growth seems to decline most steeply in English-speaking countries, which could reflect some sort of information dissemination.

And yet, I’m skeptical. Health care is not a competitive industry the way automobiles are. The British, Canadian and American systems do not much compete for patients; moreover, each is organized so differently that it’s hard to imagine all of them implementing the same productivity-enhancing measures at the same time.

Industrial diffusion is simply inherently slower than the trends we seem to be seeing -- it’s not as if Toyota invents just-in-time production, and two weeks later, it’s in every factory at General Motors. This has to be especially true in health care, where competitive pressures are limited and heavy government involvement makes major change into a ponderous process.

Technological decline seems more plausible; see this Brookings Institution paper for the extended argument. Basically, health-care innovation is expensive, and for roughly the last decade, we’ve been doing less of it. As old innovations come off patent or are refined into cheaper and better versions, costs fall.

If you think health-care innovation is all useless me-too drugs, you should be pleased that we’re getting less of it. As it happens, I don’t think that’s the case, so while I’m pleased about the budget impact, I’m less pleased at the prospect of fewer new medical technologies. The good and the bad news is that the authors of that Brookings paper don’t necessarily expect the experience of the last decade to be continued in the future -- good, because "whee, new treatments!" And bad, because, well, money.

The most worrying possibility is that this reflects a broader slowdown in how fast everything can grow. Certainly, it’s clear that the Great Recession caused a major slowdown in health-care costs everywhere; if you graph the data from the Organization for Economic Cooperation and Development, there’s a sharp, across-the-board inflection point in 2009.

Opponents of this theory argue that the slowdown also shows up in Medicare and Medicaid, and is therefore less likely to be driven by the economy. I’m not so sure. During economic downturns, states clamp down on Medicaid reimbursements, and seniors get more worried about the price of co-pays and supplemental insurance because they’re at best imperfectly insulated from economic problems.

Over the long term, there’s only one way to find out if this is great news, and that’s to wait and see what happens -- to our budgets and to our health. In the meantime, I’m afraid that the happiest stories also look the least likely to me.

To contact the author of this article: Megan McArdle at mmcardle3@bloomberg.net.

To contact the editor responsible for this article: James Gibney at jgibney5@bloomberg.net.

 

[ballz]

http://www.theglobeandmail.com/globe-debate/apples-to-apples-canadas-health-system-underperforms/article19351870/?utm_content=buffer3d879&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer

Apples to apples, Canada’s health system underperforms

Relatively expensive and underperforming. These words describing Canada’s health-care system are now widely accepted in political and medical circles – in contrast to what we heard as recently as a decade ago, when “experts” and politicians still insisted that Canada had one of the best systems in the world.

But is Canadian health care underperforming as badly as the Commonwealth Fund believes? We can only hope not, because if the U.S.-based foundation is even remotely correct, Canada’s system needs even more work than had been feared.

Recently, the foundation released a comparative scorecard of 11 health-care systems in advanced industrial economies. The United States ranked 11th. Canada ranked 10th, its worst standing in the comparison since it began in 2004.

The Commonwealth Fund focuses on U.S. health care but keeps an eye on other systems, if only to show Americans the weaknesses of their own system. If it has an agenda, apart from solid research, it’s to push for more public health care. It does not promote or favour an extension of private medicine. It’s not a right-wing group blasting away at “socialist medicine.” In this study, as in previous ones, it argues that “the most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage.”

Philosophically, therefore, it is in the same corner with countries having largely public systems, such as Canada. So when Canadians knowledgeable about health care read Commonwealth Fund reports – and they do – they pay less attention to its criticisms of the U.S. system and focus on Canadian comparisons to the other largely public systems. That’s the apple-to-apple comparison. Alas, the comparison is discouraging: Canada stands dead last among them.

Until this year’s report, the Commonwealth Fund had compared just seven countries: the United States and six others, including Canada. Canada had previously ranked fourth, fifth and sixth, with the U.S. always last. This time, the Fund added four more countries: France, Norway, Sweden and Switzerland. Not surprisingly, Canada ranked below them, plus the five other public health-care countries: Australia, Germany, the Netherlands, New Zealand and Britain.

No single international comparative study is definitive. Each one – and there are many – asks different questions, uses different methodologies, weights answers differently. Some are highly technical. Some focus on crunching numbers. Some focus on patient or provider surveys, which are by definition more subjective. Some try to blend approaches.

The Commonwealth Fund leans toward satisfaction surveys by health-care providers and patients. So it’s more subjective, for instance, than reports from the OECD, which are heavy on details of what services are provided, outcomes from medical procedures, the number of doctors, nurses, beds, long-term care facilities and the like. In the OECD survey, Canada scores high on cost but at least average in overall performance.

The Commonwealth Fund examines 80 indicators of performance, many of them based on patient surveys. Canadian respondents were by far the most numerous of any country, which suggests a somewhat greater accuracy than the results for other countries.

Of course, Canada was ranked last of the 11 for “timeliness of care.” Canada always comes at or near the bottom in many studies for long wait times – at all levels of service, from family doctors to specialists to surgeries to long-term care. In none of the categories does the Fund put Canada at the top. In very few categories is Canada even near the top.

We’ll see if Canada improves in future surveys. Some of the Fund’s survey questions were highly subjective. To their credit, provincial governments are pursuing long-overdue reforms. Without the false fix of more money and the phony rhetoric about Canada being No. 1, people in politics and the health-care system are thinking about new and better ways of doing things. Measurable progress is evident in some places.

But other countries aren’t standing still. The Commonwealth Fund study illustrates how much work remains for Canadians, and how other systems do work better.

I have put a bit of thought into healthcare reform. There is no doubt that that the private market would be more efficient. That said, there is something to be said about leaving the less fortunate completely out to dry. While a "pure" libertarian approach would suggest that with all the extra wealth in a libertarian society, people would be free to support various charities and community organizations or churches to support the less fortunate in their community in a way that they see more fit, this part of the utopia never actually plays out in the real world.

For healthcare reform, I would like to hear your thoughts / critiques / queries on this:

1. Completely privatize the market.

2. Allow all citizens the choice to choose any private insurance package they want from any insurance company.

3. Have the provincial governments select an insurer from the private market through a competitive process. This will:

        a. Mean the provincial governments are able to select an adequate level of care, at the most competitive price; and

        b. With 13 provincial governments plus all private citizens looking for insurance, keep the market competitive.

4. All persons under 18 will be, at minimum, covered by the provincial policy.

*5. All persons making under 20k per year will be covered by the provincial policy for free, and can purchase additional insurance if they wish.

*6. All persons making between 20k - 30k a year can pay 25% of the premium to be covered by the provincial plan, and can purchase additional insurance if they wish, - or - can choose their own policy on the private market and pay the full premium.

*7. All persons making between 30k - 40k a year can pay 50% of the premium to be covered by the provincial plan, and can purchase additional insurance if they wish, - or - can choose their own policy on the private market and pay the full premium.

*8. All persons making between 40 - 50k a year can pay 75% of the premium to covered by the provincial plan, and can purchase additional insurance if they wish, - or - can choose their own policy on the private market and pay the full premium.

*9. All persons making over 50k a year can pay 100% of the premium to be covered by the provinicial plan, and can purchase additional insurance if they wish, - or - can choose their own policy on the private market and pay the full premium.

The effect here is as follows:

1. Private insurers would want the provinces to choose their package because of the potential to make HUGE profits, so the provincial plan would be of great value.

2. The provincial plan has basically become a "group insurance" plan, but you have the option to shop elsewhere if you so choose.

3. Obviously, because the provincial plan is subsidized for certain people (minors, the poor, and the lower-middle class), there will still be some taxation of the rich. However, the tax burden on the wealthy will be a fraction of what it is now because the private market will be much more efficient at providing insurance, and because a much smaller amount of Canadians receive coverage. The world isn't perfect or else there would be no gov't subsidies required, but this is much better than what we currently have.

*Note for points 5 - 9... I haven't actually crunched any numbers on this. The idea is simple, a graduated expectation on the individual, based on their income, that they will look after themselves. Brackets would probably need to be adjusted, and method of subsidizing may also. For example, why would someone making $19,999 want to earn another dollar if it means they will have to pay 25% of their healthcare premium. Certainly, the details of points 5 through 9 are not ironed out, but the point is to demonstrate the intent.

EDIT: I originally posted this on the Libertarian Party of Canada Facebook page, so I had to take out some of the wording that was meant for that audience that does not necessarily apply on this forum.

 

[a_majoor]

As a contrast to what you are proposing, the real situation on the ground in the U noted States is that larger numbers of doctors have simply abandoned the bureaucratic (Medicare/Medicaide) and health insurance/Obamacare markets entirely and have set themselves up as exclusively private practitioners. These cash only practices (often known as Concierge Medicine) are generally smaller, run at a slower pace (no 15 minute "in and out" appointments) and the doctors control the patient intake as a means of setting their own quality of life.

The point here is that heavily regulated and bureaucratized systems have large negative incentives for the people trapped within, as well as lots of seams for people to "game" the system (much like your example of a person making $19,999 not wanting to advance to the next bracket). There is no one solution, and indeed there should not be any consideration of a "one size fits all" market. It does not work in any other field, from buying groceries to hiring skilled labour, so why should it be expected to work in medicine?

As a checksum, you can consider the situation in Ontario, where there is a huge shortage of doctors and medicinal support staff (many families cannot get a doctor at all), to the relatively less regulated field of dentistry, where new dentists set up practice all the time and "New Patients welcome" signs grace most dental practices. I suspect that if the Canada Health Act were abolished there would be a 10 year period of flux (mostly because it takes about that long for new doctors to get through the pipeline) and then a multi tier system of practices would have settled in place, ranging from low cost clinic settings to individual private practices, and many things in between.

 

[Colin Parkinson]

I think you find that the large companies once established will be the first to push for regulations to prevent competition. Free market is not going to touch anyone who will cost money and has little of it. That's why we went with healthcare in the first place, because we had private healtcare and it underperformed for the average person. That's not to say that the current system is sustainable, but I would rather see more mixing of the 2 and reducing bureaucracy both within government and business. If you do deregulate, you will need a robust regulatory unit that can investigate and punish those who screw people. That will require political stones, which generally are lacking, because as soon as you come down hard on the wankers, they will go bleating to the politicians about big bad regulators.

 

[Edward Campbell]

A new infographic from The Economist:

Now, clearly, we would like to spend like Finland and have outcomes like Japan but, look at Australia, a country much like us - they spend less than us, by a full 2% of GDP and they have somewhat better outcomes in deaths per 100,00 from both non-communicable diseases and accidents. What are they doing right? Look at Fig 2.1 here; there is substantial private money in all segments. Private funding tends to create efficiency, in my opinion.

 

[pbi]

I tend to agree, cautiously. While I still believe that the principles underlying our health care concept (I hesitate to call it a "system") are very fine and honourable Canadian ones, I think that more private service provision is good, provided we have appropriate regulation to ensure that the bottom line doesn't become the driver for everything.

After all, isn't the drugstore a vital part of the healthcare system? But who, in their right mind, proposes that drug stores should be run by the Govt?

As long as standards are met, and the same level of access is available, and nobody lacks for care because they don't have the means, then I have no problem that health care services are delivered by private operators.