By Rhonda Hackett
The Denver Post, June 7, 2009

As a Canadian living in the United States for the past 17 years, I am frequently asked by Americans and Canadians alike to declare one health care system as the better one.

Often I’ll avoid answering, regardless of the questioner’s nationality. To choose one or the other system usually translates into a heated discussion of each one’s merits, pitfalls, and an intense recitation of commonly cited statistical comparisons of the two systems.

Because if the only way we compared the two systems was with statistics, there is a clear victor. It is becoming increasingly more difficult to dispute the fact that Canada spends less money on health care to get better outcomes.

Yet, the debate rages on. Indeed, it has reached a fever pitch since President Barack Obama took office, with Americans either dreading or hoping for the dawn of a single-payer health care system. Opponents of such a system cite Canada as the best example of what not to do, while proponents laud that very same Canadian system as the answer to all of America’s health care problems. Frankly, both sides often get things wrong when trotting out Canada to further their respective arguments.

As America comes to grips with the reality that changes are desperately needed within its health care infrastructure, it might prove useful to first debunk some myths about the Canadian system.

Myth: Taxes in Canada are extremely high, mostly because of national health care.

In actuality, taxes are nearly equal on both sides of the border. Overall, Canada’s taxes are slightly higher than those in the U.S. However, Canadians are afforded many benefits for their tax dollars, even beyond health care (e.g., tax credits, family allowance, cheaper higher education), so the end result is a wash. At the end of the day, the average after-tax income of Canadian workers is equal to about 82 percent of their gross pay. In the U.S., that average is 81.9 percent.

Myth: Canada’s health care system is a cumbersome bureaucracy.

The U.S. has the most bureaucratic health care system in the world. More than 31 percent of every dollar spent on health care in the U.S. goes to paperwork, overhead, CEO salaries, profits, etc. The provincial single-payer system in Canada operates with just a 1 percent overhead. Think about it. It is not necessary to spend a huge amount of money to decide who gets care and who doesn’t when everybody is covered.

Myth: The Canadian system is significantly more expensive than that of the U.S.

Ten percent of Canada’s GDP is spent on health care for 100 percent of the population. The U.S. spends 17 percent of its GDP but 15 percent of its population has no coverage whatsoever and millions of others have inadequate coverage. In essence, the U.S. system is considerably more expensive than Canada’s. Part of the reason for this is uninsured and underinsured people in the U.S. still get sick and eventually seek care. People who cannot afford care wait until advanced stages of an illness to see a doctor and then do so through emergency rooms, which cost considerably more than primary care services.

What the American taxpayer may not realize is that such care costs about $45 billion per year, and someone has to pay it. This is why insurance premiums increase every year for insured patients while co-pays and deductibles also rise rapidly.

Myth: Canada’s government decides who gets health care and when they get it.

While HMOs and other private medical insurers in the U.S. do indeed make such decisions, the only people in Canada to do so are physicians. In Canada, the government has absolutely no say in who gets care or how they get it. Medical decisions are left entirely up to doctors, as they should be.

There are no requirements for pre-authorization whatsoever. If your family doctor says you need an MRI, you get one. In the U.S., if an insurance administrator says you are not getting an MRI, you don’t get one no matter what your doctor thinks — unless, of course, you have the money to cover the cost.

Myth: There are long waits for care, which compromise access to care.

There are no waits for urgent or primary care in Canada. There are reasonable waits for most specialists’ care, and much longer waits for elective surgery. Yes, there are those instances where a patient can wait up to a month for radiation therapy for breast cancer or prostate cancer, for example. However, the wait has nothing to do with money per se, but everything to do with the lack of radiation therapists. Despite such waits, however, it is noteworthy that Canada boasts lower incident and mortality rates than the U.S. for all cancers combined, according to the U.S. Cancer Statistics Working Group and the Canadian Cancer Society. Moreover, fewer Canadians (11.3 percent) than Americans (14.4 percent) admit unmet health care needs.

Myth: Canadians are paying out of pocket to come to the U.S. for medical care.

Most patients who come from Canada to the U.S. for health care are those whose costs are covered by the Canadian governments. If a Canadian goes outside of the country to get services that are deemed medically necessary, not experimental, and are not available at home for whatever reason (e.g., shortage or absence of high tech medical equipment; a longer wait for service than is medically prudent; or lack of physician expertise), the provincial government where you live fully funds your care. Those patients who do come to the U.S. for care and pay out of pocket are those who perceive their care to be more urgent than it likely is.

Myth: Canada is a socialized health care system in which the government runs hospitals and where doctors work for the government.

Princeton University health economist Uwe Reinhardt says single-payer systems are not “socialized medicine” but “social insurance” systems because doctors work in the private sector while their pay comes from a public source. Most physicians in Canada are self-employed. They are not employees of the government nor are they accountable to the government. Doctors are accountable to their patients only. More than 90 percent of physicians in Canada are paid on a fee-for-service basis. Claims are submitted to a single provincial health care plan for reimbursement, whereas in the U.S., claims are submitted to a multitude of insurance providers. Moreover, Canadian hospitals are controlled by private boards and/or regional health authorities rather than being part of or run by the government.

Myth: There aren’t enough doctors in Canada.

From a purely statistical standpoint, there are enough physicians in Canada to meet the health care needs of its people. But most doctors practice in large urban areas, leaving rural areas with bona fide shortages. This situation is no different than that being experienced in the U.S. Simply training and employing more doctors is not likely to have any significant impact on this specific problem. Whatever issues there are with having an adequate number of doctors in any one geographical area, they have nothing to do with the single-payer system.

And these are just some of the myths about the Canadian health care system. While emulating the Canadian system will likely not fix U.S. health care, it probably isn’t the big bad “socialist” bogeyman it has been made out to be.

It is not a perfect system, but it has its merits. For people like my 55-year-old Aunt Betty, who has been waiting for 14 months for knee-replacement surgery due to a long history of arthritis, it is the superior system. Her $35,000-plus surgery is finally scheduled for next month. She has been in pain, and her quality of life has been compromised. However, there is a li
ght at the end of the tunnel. Aunt Betty — who lives on a fixed income and could never afford private health insurance, much less the cost of the surgery and requisite follow-up care — will soon sport a new, high-tech knee. Waiting 14 months for the procedure is easy when the alternative is living in pain for the rest of your life.

Rhonda Hackett of Castle Rock is a clinical psychologist.

http://www.denverpost.com/opinion/ci_12523427

By Marcia Angell
NYTimes
June 5, 2009

There would be no need for an individual mandate in a single-payer system, since everyone would be covered automatically and it would be paid for through their income and payroll taxes. So asking me, a supporter of a single-payer health system, about mandates is a little like asking someone whether he’s stopped beating his wife.

Only a single-payer system would stop the private insurance industry from holding us hostage.

But even within our current system, I’m troubled by the notion of an individual mandate. I live in Massachusetts, where we have one. It requires people to buy private insurance at whatever price the companies choose to charge. As might be expected, this is a windfall for the insurance industry. Premiums are rising much faster than income, benefit packages are getting skimpier, and deductibles and co-payments are going up.

Many people can’t afford the premiums for the best plans, and so have to choose bare-bones, low-premium plans with high deductibles and co-payments. They are then left with insurance that they might not be able to afford to use, but have to purchase anyway.

A mandate is also extremely regressive. In Massachusetts, mandated insurance and co-payments can amount to nearly a third of income. Income taxes apportion the costs of public services more fairly, and I see no reason not to adopt that approach in paying for health care. To be sure, President Obama has said he would exempt people from the mandate who couldn’t afford to purchase their own health insurance. But aren’t these precisely the people most in need of it? Massachusetts has exempted 62,000 people from the mandate for that reason.

I would hope the President and Congress would come up with something less regressive and truly universal, and stop holding the rest of us hostage to the private insurance industry.

Marcia Angell is a senior lecturer in social medicine at Harvard Medical School and former editor-in-chief of the New England Journal of Medicine.

http://roomfordebate.blogs.nytimes.com/2009/06/04/should-health-insurance-be-mandatory/

By Michael McCord
New Hampshire Business Review
Friday, June 5, 2009

Portsmouth physician Thomas Clairmont — who has practiced medicine since 1977 and is a vocal member of Physicians for a National Health Program — considers the current health reform effort a dog-and-pony show.

As he watches the health-care reform debate in Washington — mostly with frustrated amusement — Dr. Thomas Clairmont, a primary care physician in Portsmouth, can offer his own diagnosis and prescription for what ails health care in this country in five minutes or less.

Clairmont, who has practiced medicine since 1977 and is a vocal member of Physicians for a National Health Program, considers the reform effort in Congress a dog-and-pony show produced by the health-care industry for public consumption.

“We aren’t having a debate right now. We’ve seen it before, and this usually leads to nothing significant happening,” said Clairmont, who advocates a government-run, single-payer solution — one that a bipartisan majority of politicians and President Obama are ignoring as best they can, he contends.

“Who is Senator (Max) Baucus (chair of the Senate Finance Committee, which is shepherding health-care legislation through the Senate) and how is that he will determine what kind of reform we will have?”

In May, a few PNHP doctors were arrested at a Senate hearing chaired by Baucus after they protested the exclusion of single-payer advocates from testifying. Clairmont said the Obama administration attempted a similar snub at its national health-care forum in March when it originally invited no single-payer supporters — even Rep. John Conyers, D-Mich., who has introduced single-payer legislation in Congress.

“I’m not a radical. I like taxes low and limited government spending, but health care should be a right and not a privilege,” Clairmont said. “We are hearing talk about reform and fears about socialized medicine or single-payer being politically unfeasible — but our plan is simple and it will save money because it focuses on health care and not making money for the insurance industry. And we are frustrated because it’s not being taken seriously.”

What’s at stake in health-care reform is a battle over money and how it will be allocated. According to the Centers for Medicare and Medicaid Services, health-care costs will total $2.5 trillion in 2009, or about 15.5 percent of the country’s gross domestic product. Health-care spending per person is estimated at $8,100 per person — while more than 47 million Americans have no health insurance, a statistic determined before the recession.

Clairmont concedes the fight isn’t easy but he says it’s necessary because if the latest reform effort plays out as he believes it will, they will be back to square one within the next three to five years.

Q. How long have you been a single-payer advocate?

A. In 1994, I attended the New Hampshire Medical Society meeting in which the then-AMA president from Maine debated Dr. David Himmelstein, the founder of PNHP. It wasn’t even close, as the facts Himmelstein presented were extremely persuasive and the AMA position — status quo, really — didn’t come anywhere near offering the comprehensive affordable portable coverage of single payer.

Q. How do you describe a single-payer system?

A. Usually I can explain it in seconds. It will cost 4.5 percent in taxes, and there will be no premiums, no pre-existing condition restriction and no tying health care to employment. Because we eliminate health insurance companies and the system is administered by the federal government, we can save $360 billion to $400 billion a year in administrative costs.

Q. How do you counter arguments that the single-payer approach is “socialized medicine?”

A. I have two responses to “socialized medicine.” The usual one that doctors are not employed by the government and the hospitals are independent as well. Also, patients have free choice in our system of doctor and hospital. And they can see doctors here in Portsmouth, go to a specialist in Boston, or if in Florida they can get care there by other private doctors.

Socialized systems employ doctors and they own the hospitals like the VA here or the U.K.

I often ask the question as to whether Medicare is socialized medicine, and the response is usually no. But if they say no, I ask why they wouldn’t want to expand such a wonderful system for seniors to everyone else. And I ask, can you imagine if Medicare didn’t exist today what would seniors do?

If they say yes, then I ask if they would propose eliminating such a ‘socialized’ system and replace it with something else — usually there is not much for them to say.

Q. As a physician, do you see any rationale need for health insurance companies as part of the health-care system?

A. No. People care about their health-care coverage and how much they are paying for it. They don’t care about their health insurance company.

What bothers me is listening to stories like I did at the 2007 Obama health-care forum in Portsmouth — or reading stories everywhere about patients not able to afford care, tests, medicines, or in severe debt because of medical problems.

I contrast that data with the exorbitant profits and multimillion-dollar salaries of some health-care system executives. I often contrast those salaries with the salary of Health and Human Services Secretary (Kathleen) Sibelius — $191,500, for taking care of over 40 million Medicare recipients and over 400,000 patients with renal failure (which makes anyone eligible for Medicare at any age) and anyone with Lou Gehrig’s disease — that is a lot of patients with serious illnesses.

One of the main questions I always come back to is this: Why are our premiums paying for the bonuses of health insurance industry executives? Also, I tell people we are heading for single-payer anyway, and what matters is if we want the government to administer it or for-profit insurance companies running the show, even more than they already are?

Q. What do you hope to accomplish?

A. We should be able to do side-by-side comparisons to see what’s best for the country. If our plan falls short, then fine, and at least we’ve had a debate. But so far Congress has mostly been doing the work of the health-care industry.

For example, a few weeks ago the health-care industry announced it could come up with $2 trillion in savings over 10 years. But a single-payer plan would conservatively save more than $3.5 trillion over 10 years. Why aren’t more politicians giving it (single-payer) further study if cost savings are a top priority?

We are seeing more support across the country as people become aware of what’s happening.

Q. What is your minimum hope for this round of health-care reform?

A. At a minimum, I would like to see Medicare expanded to cover the spouse of a person who is turning 65 and entering the Medicare system. Commonly, a spouse who is several years younger can have medical issues which do not allow them to buy into the individual market. I would give them the choice of buying into the Medicare program at that time of enrollment at the current per capita cost of Medicare. Retirement and a lifetime of savings can be quickly destroyed by a medical illness.

http://nhbr.com/apps/pbcs.dll/article?AID=/20090605/PEOPLE/906039958