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Old 07-24-2007, 08:31 AM   #21
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Not that this is a good thing, but in America, even if someone is uninsured, they still can get their emergent care for free in an ER, so you really can't count urgent and acute care as something that the uninsured don't have access to.
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Good point if true. Is that true? I've always had free health care in the US (military) so I really don't know. Is that a state by state thing?


An emergency room has to treat people to the point of stabilization. It is not free. If you are not insured, you still owe for the treatment. Some hospitals can be quite aggressive in their attempts to collect.

This is a problem, not a solution.
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Old 07-24-2007, 09:33 AM   #22
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Since you brought it up, I hadn't heard that before, can you explain further? That sounds like interesting economics. Can we apply that model to our own system or is it only for Canadians who have figured it out how to rip off the system?
Soon - Here is a good article explaining how poorer nations are able to obtain cheaper drugs (from USA pharmaceutical companies) and why the pharmaceutical companies agree to separate markets and supply cheaper drugs to poorer nations. It all boils down to the fact that the pharmaceutical companies are able to make up for the losses by charging higher prices to Americans:

Pharmacy Times: Rx Reimportation and Importation: Panacea or Prelude to Disaster?

And here is an interesting video/documentary regarding wait times in Canada:

On The Fence Films :: Movies
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A Canadian's Perspective on Health Care
Old 07-24-2007, 10:04 AM   #23
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A Canadian's Perspective on Health Care

A Canadian's Perspective on Health Care
Canadian medicare is administered by the provinces. The national program is a set of standards and some funding. Each province has some wiggle room. Ontario completes its funding through a payroll tax whereas BC charges $54/mo per individual ($99/mo for a family). Poor people have the payment waived. Employed people have it paid by their company. There is a 3-month wait time to qualify to avoid drop-in health care. Hospitals also do private fund-raising for improvements to their facilities.

National medicare insurance grew out of an implementation in one province (Saskatchewan). After five years it had proved to be cost effective in improving medical services and saving money. It was promoted to national status. It has proven to be cost-effective. Some side effects include less income for our doctors, but recently also substantially less liability insurance to balance off their lower income.

There are some abuses from people going to the doctor for every ache or pain or even for colds and the flu. But on average it privides good medical repair services for the money.

Here is the latest data on wait times for major surgery in BC. Average wait time for the province is under 4 months. My hospital, Vancouver General, is about half that.

The wait list data can be troublesome. But the statistic about operations performed during the quarter in the specific hospital are the most accurate, because they have to report this accurately to get paid.

People that don't know the system try to infer that wait times are bad. The government does not determine the supply. That is done by the free market. Because access to specialists is "free", there are no artificial constraints on demand. And, yes, urgent cases are handled on a priority basis. First time referrals usually take the longest unless they are urgent.

(DW and I are both going in for colonoscopies from the same GP. It is her second time and she gets it in 2 months, I wait 6 months because it is my first time. Both are routine screening so not urgent.)

There are some user-pay choices. I can get a virtual colonoscopy tomorrow if I want peace of mind and am willing to open my wallet. Lens implants come in two versions. The new improved foldable ones have a user-pay premium of $300 whereas the standard lens is free.

There are many walk-in clinics for routine items like kids' earaches to avoid overloading either the GP or hospital emergency. More serious emergencies such a broken bones require emergency ward treatment and these tend to be overloaded at certain times resulting in extended wait times. All the life-threatening cases get handled first, e.g. bleeding, concussions.

The Canadian walk-in clinics offer the convenience of being in your neighbourhood and are usually faster - 15 minutes instead of 30 minutes waiting in the emergency ward. And parking is often free as well.

There are two tiers for many things already. Blue Cross insurance provides many enhancements such as semi-private hospital rooms, wheel chairs, nursing in the home...

Private company insurance covers dental, drugs, eye care coverage (glasses, lens). And even in the core services such as opthamology, cataract surgery is covered but the new foldable lens are a $300 option. Laser surgery corrective procedures are not covered by anyone.

Also, there have been many improvements in the last 5 years to the basic services through infusion of new cash. The feds went through a period of cutbacks to balance their budget. But they have been running increasing budget surpluses for over 5 years and this enabled them to open the purse a bit further. Most of the press has been aimed at increasing pressure on the federal government and it is working. National funding for the health care system comes from general revenues and from sin taxes on alcohol, tobacco and gasoline.

But the low penetration of MRI, PET, and CT machines does not seem to causing a problem. In fact one of the problems is the CIHI's inability to tie a high penetration number to improved survival rates. IOW a business case. BTW much of the data available is pretty old and no longer representative.
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January 13, 2005A new report released today by the Canadian Institute for Health Information (CIHI) shows Canada had 151 MRI scanners at the beginning of 2004, more than four times the number it had a decade ago (40), and up from 144 the previous year. The report, Medical Imaging in Canada, 2004 also notes a 44% increase in the number of CT scanners during the last decade, from 234 to 338. Since 1997, more MRI scanners than CT scanners were installed.
I guess if I was diagnosed with a brain tumor, I would pay to go to The Mayo Clinic for my MRI and treatment. There are certain things where money is no object. But I would not want anyone claiming it is because I could not get it in Canada.

We had quite an exodus to the US of experienced doctors about ten years ago. This made it hard to get into see a doctor when you moved. You always could if your knew how to work the system. This gave impetus for high growth of the walk-in clinics. New doctors saw it is a fast way to establish a practice and share costs.

Last year there was a net influx of doctors from the US because, after paying for the escalating malpractice insurance, they were netting less for the first time in decades. There are still areas underserviced. When my son moved his family to Belleville east of Toronto, it took a year to get a new family doctor there. This was four years ago. They used walk-in clinics but everyone likes to have a family doctor.

Canadians Healthier Than Americans, Survey Says - Forbes.com
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Canadians are healthier than Americans, have better access to health care and have fewer unmet health needs, a new study of both countries reveals.
...
While Americans were more likely to identify cost as the impediment to care, Canadians were more likely to cite waiting times as their main obstacle to good care. However, just 3.5 percent of Canadians were impacted by treatment delays, the survey found.
Beware much of what you hear. There are strong lobbies with deep pockets aligned against any national health initiatives. Here is an example of what 60 Minutes reported on one such lobbyist (albeit not for the HMOs yet): Rick Berman is an expert on PR campaigns.
Quote:
"If the government is truly interested in my health and welfare, I'm appreciative of it. But, I think I can take care of myself," Berman tells Safer.
He seems to be effective at helping the fight against The Nanny State on behalf of big corporations.

Epilog:
You should not expect more taxes. It should be a shift of premiums from many dozen insurance companies to a few. Taxpayers should demand a reduction in the administrative costs. All the staff needed to deny claims and also deny new applicants will vanish, estimated to be over 30% of the cost of care. Just 16% of that cost would cover the uninsured.

Shortages may be driven by higher demand when 47 million new claimants start using the systems. This is the trickiest transition. New capacity must be added as new claimants are added. This will create a demand for capital that must be satisfied efficiently. Introduction of more walk-in clinics might help the transition.

I went back and ressurected a piece I put together a couple of years ago. I was considering retirement to the sunbelt areas of San Diego (La Jolla, Del Mar, Coronodo Island), Palm Springs or Scottsdale:
US Health Care Issues
It seems to be as relevant today as it was then. The US has big growing problems with health care:
1) Rapidly escalating costs
2) Increasing profit margins for HMOs
3) Companies reducing coverage, introducing copays, and downsizing older workers.

The US system spends 17% of GDP on health care yet sees 50% of personal bankruptcies directly attributable to medical bills, and 47 million have no access at all. Canada spends 9% of GDP on health care and everybody has access to it.
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Old 07-24-2007, 10:08 AM   #24
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Soon - Here is a good article explaining how poorer nations are able to obtain cheaper drugs (from USA pharmaceutical companies) and why the pharmaceutical companies agree to separate markets and supply cheaper drugs to poorer nations.
From your link:
"Drug company officials have accepted Canada's price controls because of its isolated, small market segment; they know that larger markets will offset the differential. Drugs are "artificially"cheaper in Canada; a truly competitive market would force drug prices in Canada and the United States to be comparable"

This sounds to me like collective bargaining, not an "artificially cheap" price. If the drug companies have agreed to that price, I assume they think it's a fair price. If they then turn around and charge US citizens higher prices to make up for losses, could I conclude the US price is "artificially high?"

In the end, it takes $X per dose to research, manufacture, and sell a drug, and make a reasonable profit. If X is beyond the means of those in need, what do you do? If we were producing cars, no problem, the rich buy Ferraris and the poor buy Chevys. But when it's someone's life, do you let the rich live and the poor die?

I have a family member that needs Gleevec or they die. It costs $2400 per month, $28,800 per year. That does not include the tests and doctor visits, I mean just the one pill per day. Fortunately they have insurance and can afford it. I'm not going to argue the price is artificially high, let's say that's really what is needed to provide enough incentive to manufacture Gleevec. What would be your solution for those who have no insurance, or have insurance but could not afford the copay?
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Old 07-24-2007, 10:39 AM   #25
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Not that this is a good thing, but in America, even if someone is uninsured, they still can get their emergent care for free in an ER, so you really can't count urgent and acute care as something that the uninsured don't have access to.

Finance Geek makes a good point when he states that you can't always tell what diseases are in need of immediate care and what diseases are not, and in countries with wait times, people can and do die while on waiting lists. It is impossible to find published information on these stats, because the govt's don't want their people to know the actual stats.

I've heard horror stories about people in need of hip or knee replacements getting hooked on pain killers while on waiting lists, and then, if they don't commit suicide while on the waiting list due to having to deal with the chronic pain, they cost the gov't a small fortune in mental health services trying to get over their pain killer addictions. I've also heard of people having to live in complete blindness while waiting for cataract surgery. This is unheard of in the USA.

We've got to get a handle on inflation, but not through a single payor system. I still have faith that the solution lies in combination of public/private efforts.
My 2 cents:

A person without insurance who receives care in an emergency room can quickly financially devastate their family. The cost of care for those with no finances to devistate is born by those who can pay, so they end up paying more than their cost of care.

People can and do die while in the 'infinite' wait list of the uninsured because they can't afford treatment.

The uninsured can and do need hip and knee replacements and may become addicted to pain killers obtained through the underground market today. HOWEVER, most of these patients are older and many wait until Medicare kicks in for treatment. Take a look at the utilization figures for the first two years of Medicare.. much of it is deferred care.

I too believe that we need some kind of universal insurance with the option of folks purchasing additional coverage from the private market. If we don't have the equipment/medical resources to meet the demand the additional coverage will enable some to outsource to India and Thailand.
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Old 07-24-2007, 10:41 AM   #26
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I guess if I was diagnosed with a brain tumor, I would pay to go to The Mayo Clinic for my MRI and treatment. There are certain things where money is no object. But I would not want anyone claiming it is because I could not get it in Canada.
What if America had a single payor system and a shortage of specialists and MRIs for Brain Tumor diagnosis? Where would you go then? Sure, you could get it EVENTUALLY in Canada, but would it be too late?

Watch this video On The Fence Films :: Movies (a Short Course in Brain Surgery) about someone who needed a brain scan in Canada. He was placed on a long wait list, but didn't want to wait because of suspected cancer. He went to Buffalo to get his MRI (which showed cancer), yet Canada still wanted him to wait another 3 months for surgery. If he would have waited, he would have had incurable cancer. He went to the USA for surgery and spent a large sum of money to do that (could the average Canadian afford to leave Candada for brain surgery?). Canada refused to pay for the surgery because he didn't wait for permission which would have taken just as long as the wait for the surgery.

Single payor systems work WONDERFULLY for routine, preventive and acute care, but NOT SO WELL for complicated health problems requiring expensive diagnostics and the services of highly specialized doctors. Canada's system seems great to most people because MOST people don't need to have highly specialized care and don't experience dealing with the system for that purpose....but when they do need it, the tune changes...

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Last year there was a net influx of doctors from the US because, after paying for the escalating malpractice insurance, they were netting less for the first time in decades. There are still areas underserviced. When my son moved his family to Belleville east of Toronto, it took a year to get a new family doctor there. This was four years ago. They used walk-in clinics but everyone likes to have a family doctor.
Was this an influx of specialists or primary care physicians? I doubt it was specialists, which, when it comes to major health problems, is what you really NEED!


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The US system spends 17% of GDP on health care yet sees 50% of personal bankruptcies directly attributable to medical bills, and 47 million have no access at all. Canada spends 9% of GDP on health care and everybody has access to it.
I hate when people throw around these stats. We spend more on healthcare because we CAN. In Canada, prices are fixed, so it's not hard to put a limit on inflation. Our figures include the cost of care for people who leave other countries and get care in the USA when they can't get it in a timely manner in their own country.

Just because someone doesn't have health insurance doesn't mean they have no access to care. They can always pay out of pocket if they want to, and for routine care, it's not really that much more expensive to do that than health insurance itself. People in America will spend $20,000 on a new car, but when it comes to their own healthcare, they don't want to spend a dime.

Major medical insurance above a certain deductible is fairly inexpensive if you buy it BEFORE you get sick. Health insurance is most important for people with major medical problems. The great majority of uninsured people are not in urgent need of major medical services. I talk to people everyday who can easily afford a major medical plan but choose not to purchase it. That's their CHOICE. In fact a LARGE chunk of the uninsured population include people who CHOOSE not to buy it, even when they can afford it. Only a small percent of the uninsured are unwillingly uninsured AND in great need of expensive services (probably about 2-5%).
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Old 07-24-2007, 10:51 AM   #27
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Ok, let's assume we don't have enough specialists to meet the need if everyone had insurance...

Will the rate of disease increase because more are insured If not, obviously there are a lot of people who NEED TREATMET TODAY who aren't receiving it because they can't pay for it.
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Old 07-24-2007, 11:53 AM   #28
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What would be your solution for those who have no insurance, or have insurance but could not afford the copay?
I say that it would be wonderful to give everyone the drugs they need for free, BUT, that would be idealistic. In the real world, there has to be some kind of rationing. In a single payor system, perhaps the unique drug for the rare health condition wouldn't be available to ANYONE. In America, the drug may be there but unaffordable to some. HOWEVER - At least in America, we have the ability to get it if we try hard. We can either work to pay for it if we are not disabled....we can turn to charitable organizations for help...we can get help from family and friends....we can get help from the gov't if we can qualify....we can save money in anticipation of future medical bills. In a system which places limitations on supply, there is no way to get around that.
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Old 07-24-2007, 12:32 PM   #29
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What if America had a single payor system and a shortage of specialists and MRIs for Brain Tumor diagnosis? Where would you go then? Sure, you could get it EVENTUALLY in Canada, but would it be too late?
I believe that The Mayo Clinic will always be a world class referral center no matter how badly the US messes up its health care system. I would go there because they do it a lot and see complex cases, not because of WAIT TIME.
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Old 07-24-2007, 12:44 PM   #30
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I believe that The Mayo Clinic will always be a world class referral center no matter how badly the US messes up its health care system. I would go there because they do it a lot and see complex cases, not because of WAIT TIME.
Well, IMO - I think that's wishful thinking. Why doesn't Canada doesn't have a "Mayo Clinic" with enough physicians to service everyone that wants care?

If the American gov't puts a cap on specialist's salaries (like Canada does - in order for the gov't to be able to afford to provide "free care for all"), how many young, intelligent and enthusiastic people will choose the spend the money, time and energy to become world class health care professionals?... Eventually, we will lose the talent that comes with Mayo Clinic style care, and then where will you go? Sure, maybe a few people will still choose those careers, but will there be enough of them to service the "unimited" demand? If not, who will have to wait for their care? You have to look at the LONG TERM consequences of switching to a single-payor system.
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Old 07-24-2007, 01:02 PM   #31
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If the American gov't puts a cap on specialist's salaries (like Canada does - in order for the gov't to be able to afford to provide "free care for all"), how many young, intelligent and enthusiastic people will choose the spend the money, time and energy to become world class health care professionals?... Eventually, we will lose the talent that comes with Mayo Clinic style care, and then where will you go? Sure, maybe a few people will still choose those careers, but will there be enough of them to service the "unimited" demand? If not, who will have to wait for their care? You have to look at the LONG TERM consequences of switching to a single-payor system.
Well this is a big IF. What I have learned when considering a move to the US was that the cost of liability insurance is going through the roof, and that this is already taking its toll on the desirability of going into the profession.

Even worse, it is encouraging some of the existing professionals to retire early because continuing to work is not that lucrative. One successful lawsuit that exceeds their coverage can ruin them financially.

We buy commercial health insurance every year to cover us when we travel (often) and so we are seeing some of the issues in the escalating costs of that insurance. Like any insurance, it is cheap when you are young and healthy.
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Old 07-24-2007, 01:05 PM   #32
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Frankly I think it is a sin that physicians need to pay so much for their medical education, and I think interns and residents should earn a living wage. Assuming that physicians are actually paid promptly for almost all the care they provide they should be able to earn a reasonable living from services under the program. If a physician wants to provide care outside the program then so be it, but those higher earnings shouldn't be funded by tax supported tuition programs.

If physicians justify their fees because of their school loans then there could be school loan credits for services under a broader insurance program.

Insurers today negotiate fees with physicians, nothing new.

I agree that for many specialties liability insurance is an issue. As a culture we seem to think that it is a perfect world. Negligence needs to be proven, IMHO. Too many juries make awards because they feel bad for the person who has a poor outcome. On the other hand State medical societies aren't following up on complaints and supervision isn't all that it should be. In many ways they have handed off supervising to insurers . . to no one's benefit.
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Old 07-24-2007, 01:08 PM   #33
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Well this is a big IF. What I have learned when considering a move to the US was that the cost of liability insurance is going through the roof, and that this is already taking its toll on the desirability of going into the profession.

Even worse, it is encouraging some of the existing professionals to retire early because continuing to work is not that lucrative. One successful lawsuit that exceeds their coverage can ruin them financially.

We buy commercial health insurance every year to cover us when we travel (often) and so we are seeing some of the issues in the escalating costs of that insurance. Like any insurance, it is cheap when you are young and healthy.
You are correct - Malpractice insurance is a big problem here in the USA and one that needs to be addressed. Lawyers are always on the lookout to make money off of the system. In fact, they even ADVERTISE to people to come and find out if they are eligible to receive a settlement from class action lawsuits against pharmaceutical companies in particular.

On the other hand, please explain to me, then, why Canada does not have a Mayo Clinic. (Are you from Canada?).
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Old 07-24-2007, 01:25 PM   #34
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On the other hand, please explain to me, then, why Canada does not have a Mayo Clinic. (Are you from Canada?).
Is this potentially a straw man? Given that Rochester, MN actually makes it easy for Arabic speakers to get around (the downtown has many signs posted in English and Arabic), I think it's safe to say that the world feels that the Mayo Clinic is a pretty special place. After all, it's likely no faster to get from Saudi to the middle of Minnesota than it is to get to France, Spain, Germany, etc. But, to some degree, I wonder if they're the best simply because they're the best.

To expand on that, look at college football. The top college teams stay at the top for quite a while. I've heard, and it seems plausible, that this is because it's easier to get the best high school players to join a top-ranked team.

Or, look at Google, lots of smart computer nerds want to work there because lots of smart computer nerds work there.

I wonder if it's similar at the Mayo Clinic. Lots of smart medical people want to work there because lots of smart medical people work there. In other words, nothing attracts good talent like good talent.

(p.s. My wife and I used to get 100% coverage with any doctor in any specialty for $40 a month. Talk about a cool benefit)
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Old 07-24-2007, 01:50 PM   #35
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Is this potentially a straw man? Given that Rochester, MN actually makes it easy for Arabic speakers to get around (the downtown has many signs posted in English and Arabic), I think it's safe to say that the world feels that the Mayo Clinic is a pretty special place. After all, it's likely no faster to get from Saudi to the middle of Minnesota than it is to get to France, Spain, Germany, etc. But, to some degree, I wonder if they're the best simply because they're the best.

To expand on that, look at college football. The top college teams stay at the top for quite a while. I've heard, and it seems plausible, that this is because it's easier to get the best high school players to join a top-ranked team.

Or, look at Google, lots of smart computer nerds want to work there because lots of smart computer nerds work there.

I wonder if it's similar at the Mayo Clinic. Lots of smart medical people want to work there because lots of smart medical people work there. In other words, nothing attracts good talent like good talent.

(p.s. My wife and I used to get 100% coverage with any doctor in any specialty for $40 a month. Talk about a cool benefit)
IMO - America has Mayo because there is a profit motive
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Old 07-24-2007, 02:25 PM   #36
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IMO - America has Mayo because there is a profit motive
That's a very sad commentary, and I refuse to accept that the only way to get world class science (and medicine is science) in our great country is through obscene profits.

In 1961 JFK challenged us to go to the moon, something dauntingly difficult. By 1969 we had achieved it. We didn't achieve it by offering huge profits to individuals of companies, but by appealing to their sense of challenge, of patriotism, and of scientific accomplishment. These were not profit-minded people making that dream come true, they were for the most part government workers and government contractors paid for through tax money. I put myself through college partly through that, doing analysis on the tractor transporter for the Apollo launch vehicle, and even though I was paid peanuts I would not have changed that job for the world. The opportunity to be associated even in a minor way with the leading edge of astronautics at the time, and providing service to our nation at the same time, was all I needed. I just can't accept that the leading physicians and biomedical researchers in this country will stop what they are doing and go into a new line of work because we don't pay what they demand. We're not talking poverty wages either, good researchers are at the top of the civil service scale in government.
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Old 07-24-2007, 03:03 PM   #37
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Hey I'm off this thread for a day or two and WOW, lots of posts.

It is very clear to me from the various reports I've read that the Canadian system does a far better job than ours at providing universal access to most types of acute/routine care, but it comes at a substantial downside - far lower incentives for doctors and healthcare related companies to produce goods and services, and often substantial waiting periods for more complex and expensive care (some of which may not be harmful to the patient, but some of which certainly can be since its impossible to know ahead of time what you might find in any given scan/procedure).

A prior poster put it best, the goal is to improve the US system learning as much as we can from others' experience. I highly doubt a single payer system (with no private alternative) is coming to the US, when this was last brought up 15 or so years ago there was quickly an undercurrent of talk of setting up high end healthcare facilities on offshore oil drilling platforms or other sovereign territory such as Indian reservations, if necessary, to provide a private alternative.

A combined private/public system seems to be a decent mix. Perhaps the MA plan will be closer to the answer than either what Canada or US do today. Bravo to them for trying, even though its obvious that they won't get it all right on the first go. Time will produce more data.
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Old 07-24-2007, 03:09 PM   #38
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On the other hand, please explain to me, then, why Canada does not have a Mayo Clinic. (Are you from Canada?).
What Canada lacks is the extraordinary deep pockets of successful private investors. We don't have a Mayo Clinic for the same reasons that we don't have a Harvard, Yale or Stanford. This has nothing to do with government. The US is way ahead of Canada in tapping private benefactors for their "public" institutions. We are starting to get some momentum from the founders of eBay, RIM, and Celestica (Onyx). But we are way behind.

In fact, a major reason that my hospital, Vancouver General, has only 2 month lead times for major surgery is that the Pattison and Diamond families among others have been very generous.
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Old 07-24-2007, 03:10 PM   #39
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The talk of Canada's wait times mean little to me. I have had 3 MRI's over the years. Once I had a 10 week wait. Both other times the wait was well over a month. I had a accident and ended up having back surgery at Duke 2 years ago. They scheduled me almost 9 weeks out if I remember correctly and just fed me percocet in the meantime. Most everyone I have talked to has had similar wait times unless it is a true emergency.

I know someone personally who did not get chemo due to being uninsured but a homeowner and had small savings which put them out of the range for some of the free treatment but they certainly didn't have enough money to fund treatment. I suppose they could have sold thier house:confused: They had worked hard all their lives at a blue collar job but were not able to afford health insurance premiums. They passed recently at the relatively young age of 63. Would they be alive today had they had treatment? I don't know. Do we all have the "right" to cancer treatment? I don't know.

This topic is a little over my head in it's complexity but if I had a choice today I would choice Canada's system over ours. And this comes from someone who has great health insurance from their employer.
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Old 07-24-2007, 03:16 PM   #40
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Quote:
Originally Posted by FinanceGeek View Post
A combined private/public system seems to be a decent mix. Perhaps the MA plan will be closer to the answer than either what Canada or US do today. Bravo to them for trying, even though its obvious that they won't get it all right on the first go. Time will produce more data.
The Canadian system started out as an experiment in one of our prairie provinces. I think there are ways to improve on it. That is the real potential for the current momentum. Don't trash the alternatives.
Take the best features of them and go world class. Leapfrog!
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