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Next Pres. Election and Health Ins.
Old 07-21-2007, 04:34 PM   #1
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Next Pres. Election and Health Ins.

Say Candidate X wins the next Pres. election on a platform of universal health care. How does that effect the Health care industry as far as any kind of price reforms? I'm sure they will lobby for no changes to our current system (duh) but what will they say to defend the status quo? Do you think they will make it more affordable or accessible on their own to avoid legislation changing the industry?
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Old 07-22-2007, 05:28 PM   #2
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Wow now that's an interesting question.

I suspect that Hillary cannot win due to her past "work" in this area that many remember from 15 years ago, and the dems know it and won't nominate her. She would be a tremendous get-out-the-vote machine for the reps. Given the poor outcomes achieved under the Bush admin in overseas policy, I'm assuming that the dems know this election is theirs to lose and they will nominate someone who has less of a stigma with moderate voters, probably Obama, and he will be our next president.

As to your specific question I really cannot see a federal takeover of health insurance, the Canadian and European systems seem to work well to deliver what I call "universal provision of acute care", but they just don't cut the mustard for handling expensive or chronic conditions (do you want to wait 9 months for an MRI, or be told that even though there are 10 approved drugs for your condition, your Doctor will be limited to the 1 or 2 which are reimbursable?), nor do these kind of systems provide as much profit margin to fund drug or medical equipment development as today's US model - no matter how flawed today's model is, and certainly I acknowledge it has a tremendous number of flaws. To put a sharper point on it, the only reason we HAVE so many drugs and procedures under today's system is that there is a financial incentive (in the form of insurance coverage) to develop them.

When you get right down to it, consumer spending and ultimately big business have enormous influence in the US political system. I just cannot see the impetus to take away the ability to receive leading edge care from the 70% or so of Americans (or whatever the % is) for whom the current system - no matter how flawed it may be - actually works fairly OK. Nor will the many highly paid Americans who are satisfied with the current system easily accept a system that forces them to travel overseas or pay out of pocket to receive timely or leading edge care.

Personally I'm watching what's happening in MA. If everyone were required to have health insurance, and insurance companies were correspondingly limited in terms of declining or charging substantially more for pre-existing conditions, it might solve much of the adverse selection problem which pervades today's system. You'd have more of both "healthy" and "unhealthy" people in the pool versus today's situation, which might actually balance out.

This strikes me as one of those near-intractable problems...it'll be interesting to see if MA can crack this nut, and if so, does it lead to a national solution. Bravo to MA for trying, even though we know they cannot possibly get it all right with the first prototype. There will undoubtedly be weird consequences and some new perverse behaviors introduced by the MA system which were not foreseen. Beware the law of unintended consequences!
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Old 07-22-2007, 05:50 PM   #3
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As to your specific question I really cannot see a federal takeover of health insurance, the Canadian and European systems seem to work well to deliver what I call "universal provision of acute care", but they just don't cut the mustard for handling expensive or chronic conditions (do you want to wait 9 months for an MRI, or be told that even though there are 10 approved drugs for your condition, your Doctor will be limited to the 1 or 2 which are reimbursable?),
I would like to see actual unbiased data on this. I've read about those unreasonable waiting periods, and have read countering arguments, but they've all be anectdotal.

If we could provide "universal provision of acute care", I think that would be a good start for the US. I'm not sure I would describe the European system as that, at least the system I experienced for three years in Holland. I would call it at least "universal provision of routine and acute care." I never had any problems getting myself or my family seen within 2-3 days for such care, nor did I have any problem with quality of care. As far as expensive or chronic conditions, I don't know. I can only offer another anectdote, was referred to a cardiologist for tests and diagnosis (came out fine), and didn't have to wait longer than a couple of weeks, including tests. That was many years ago, though, so I don't know how it is now.

Bottom line, the current US system needs a lot of work to take care of those of below average means -- and to improve HMO-type care. I have the equivalent of socialized medicine with the military health care system, so it's not a personal issue for me, but I still think it's a very important issue for the country. I don't know what the solution is, but will be listening closely at election time, and will make this an important part of my decision on whom to vote for.

As far as the cost to our country, that's a bigger issue than health care, and it has to be addressed sooner or later. The issue is, do we want to go bankrupt with universal health care sooner, or with a combination of the existing health system and other entitlement programs a little later? In the end, we have to make some hard choices on entitlements, taxes, and distribution of income. I plan to be pushing daisies before that settles out.
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Old 07-22-2007, 06:02 PM   #4
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I would like to see actual unbiased data on this. I've read about those unreasonable waiting periods, and have read countering arguments, but they've all be anectdotal.

...snip snip snip ...

I plan to be pushing daisies before that settles out.
If you google "waiting list MRI" you can read various reports of the situation in many overseas countries just as well as I can post URLs. It seems that the most "hits" on the complaint-side were related to Canada and the UK, perhaps Holland has a better outcome. I don't know how unbiased all of this information really is, my tendency is to believe "where there's smoke...", but here's one specific link from the BBC talking about waiting lists for MRIs and other procedures and how "improved" the situation is from the past (and compared to the situation of most US folks with employer health insurance the current situation doesn't sound so good, e.g. the "goal" is to REDUCE the waiting time from GP referral to hospital treatment down to an average of 10 weeks) BBC NEWS | Health | NHS chief upbeat about progress

As to your second statement about "pushing daisies" before the problem is solved, I suspect you're right, and that not only I but my son and my grandson will be pushing 'em too!
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Old 07-22-2007, 06:31 PM   #5
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Depending on the outcome in Iraq by 2008....if nothing a Dem will win regardless, if withdrawal in some form a Dem will win regardless, if a catastrophic attack in the US - all bets are off. I do think the Presidential race is Dems to lose and if they can parlay the immigration problem, the congress as well.

For my money - I would much rather be more concerned with domestic policies instead of our present incoherent foreign policy.

Healthcare - Single-payer healthcare for every citizen is in the near future (5 years) unless the insurance companies stop the gouging.

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Old 07-22-2007, 06:35 PM   #6
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If you google "waiting list MRI" you can read various reports of the situation in many overseas countries just as well as I can post URLs. It seems that the most "hits" on the complaint-side were related to Canada and the UK, perhaps Holland has a better outcome. I don't know how unbiased all of this information really is, my tendency is to believe "where there's smoke...", but here's one specific link from the BBC talking about waiting lists for MRIs and other procedures and how "improved" the situation is from the past (and compared to the situation of most US folks with employer health insurance the current situation doesn't sound so good, e.g. the "goal" is to REDUCE the waiting time from GP referral to hospital treatment down to an average of 10 weeks) BBC NEWS | Health | NHS chief upbeat about progress

As to your second statement about "pushing daisies" before the problem is solved, I suspect you're right, and that not only I but my son and my grandson will be pushing 'em too!
Ask any Canadian if they would exchange our system with yours?
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Old 07-22-2007, 07:55 PM   #7
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Lets prairie dog this: If people were dying or suffering unduly under socialized health care, it'd be thrown out...and its adoption would have been slow or stopped.

Instead we get a lot of vague disconnected reports and surveys. If they're true and widespread, why hasnt a political candidate emerged that offers to solve this huge problem, been voted in on a landslide, and changed it?
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Old 07-22-2007, 07:59 PM   #8
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I found this in the Ottawa Citizen:

"Ottawa, in fact, appears to have the lion's share of the growing waiting list. More than 7,000 patients are on an Ottawa Hospital waiting list for an MRI. Patients are waiting an average seven months for a non-urgent, non-emergency scan."

This appears to be the worst case, an average of 7 months for an MRI, but it's for non-urgent, non-emergency cases. I assume this is because urgent and emergency cases are done much more quickly.

What I would like to see us do is to learn from the many democracies that have instituted universal health care, and find out what is working, what is not working, and what can be done better. Then we can structure out own system to be even better. I personally think our solution will be some combination of private insurance and medicare extension to those below certain income levels.

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Lets prairie dog this: If people were dying or suffering unduly under socialized health care, it'd be thrown out...and its adoption would have been slow or stopped.
Right, just like in the U.S. If our uninsured were dying or suffering under our system, it'd be thrown out. Oh, wait, it's not a govt system so can't be thrown out. So throw out the politicians. Oh, wait, most of those people don't vote. So I guess we get what we deserve.
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Old 07-22-2007, 08:19 PM   #9
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What I would like to see us do is to learn from the many democracies that have instituted universal health care, and find out what is working, what is not working, and what can be done better. Then we can structure out own system to be even better. I personally think our solution will be some combination of private insurance and medicare extension to those below certain income levels.
Well put, this is exactly what we should strive for. Few of us have a vested interest in the current system, in fact many to most of us thoroughly dislike much of it.

This is exactly why I am watching the MA "universal care" rollout so closely since that system was developed in a bi-partisan way by people who knew both the pros and cons of the Canadian/European experiences as well as the domestic situation. It won't be perfect either, but it could easily be better than what was there before.
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Old 07-22-2007, 08:57 PM   #10
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This is exactly why I am watching the MA "universal care" rollout so closely since that system was developed in a bi-partisan way by people who knew both the pros and cons of the Canadian/European experiences as well as the domestic situation. ..
Another one to look at is Australia. I was talking with an Australian professor who liked his system, with some reservations. The way he explained it, everyone pays 2% income tax to pay for the universal govt health care. But you can also opt for private insurance, and about half of Australians have private coverage. Here is a link.

Australia Now - Health Care in Australia
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Old 07-22-2007, 10:53 PM   #11
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Another one to look at is Australia. I was talking with an Australian professor who liked his system, with some reservations. The way he explained it, everyone pays 2% income tax to pay for the universal govt health care. But you can also opt for private insurance, and about half of Australians have private coverage. Here is a link.

Australia Now - Health Care in Australia
Thanks for the link, I'll have to start up the google searches for "mri wait australia" and see what emerges .

I'm inclined to believe that MRI and CT scan availability is a decent proxy for how well any health care system can cope with high cost procedures that many people are going to need. There may be other proxies to test for healthcare system efficacy towards smaller population subsets who also need expensive treatments: namely availability of specific cancer drugs, AIDS cocktails, organ transplants, etc. Again, I'd like to hear from some real Dr's about their experiences.

Off the top of my head I'd say that the explicit creation of a two tiered system is not going to sell well in the political or media arena, but its also unrealistic to not have any vestige of this. People of means have always and will always have access to goods and services above and beyond "the standard". Marx and Engels had this idea to do otherwise, but as far as I know, no society on earth has ever shown such a system to be feasible on a large scale.

Fact of the matter is that the US has (at least) two tiers in the system today, perhaps if it were made more explicit it could be less costly to administer whilst serve more people better. I'll read up more on Australia, thanks!
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Old 07-23-2007, 09:15 AM   #12
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I'm inclined to believe that MRI and CT scan availability is a decent proxy for how well any health care system can cope with high cost procedures that many people are going to need.
Maybe. Here is a link to a report that seems to have unbiased figures:
http://www.cihi.ca/cihiweb/en/downlo...it_times_e.pdf

There does seem to be a shortage of MRI equipment in certain Canadian provinces, but they also have a priority system in which the more serious cases get seen first, adding to the average waiting time for the less serious. This can make averages skew to the right, while most people's wait times are much less. Bottom line, it's easier to add more MRI equipment than it is to restructure a health care system.
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Old 07-23-2007, 09:29 AM   #13
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Thanks for the link, it does seem that (often significant) wait times are part and parcel of the Canadian health care system, even though they appear to do the best that they can with respect to handling their most urgent cases as quickly as possible. According to the report you referenced, its not just MRI and CT scans that are subject to wait times, but a wide range of surgical procedures too. And, it appears to be very dependent on what province a person is in, which makes sense given the high variability of population density in much of Canada.

Its tricky to say what a "priority case" is though. Many cancers, etc. which are "suspected" or "possible" but not "known" leading to a "routine" imaging study could have a greater chance to metastasize if one had to wait several weeks to months for the study. And a worse outcome for the patient.

I'm still leery of a system that imposes long wait times on even so-called "routine" procedures and diagnostics. You cannot know when a given situation was not really routine, except retrospectively.
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Old 07-23-2007, 10:11 AM   #14
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I'm still leery of a system that imposes long wait times on even so-called "routine" procedures and diagnostics. You cannot know when a given situation was not really routine, except retrospectively.
Agree, but I don't look at it as "imposing" waiting times, but as a result of a finite resource distributed among a fixed demand. If there are p patients, the average procedure time per patient is t, and there are m machines, the average waiting time w per machine in an ideal system without priorities is is w= p*t/m. To decrease w, you can increase m. Well, you can also decrease t through efficiencies or sloppiness but let's say that's fixed.

In a priority system, you have categories of p, p1, p2, ..., pn, so you can vary the w's depending on the priorities. The higher priorities get shorter waiting times but at the expense of the lower priorities, which provides an opportunity for those who want to play with the numbers.

Our system also has priorities, where the last priorities (the uninsured or underinsured) have infiinite waiting times, but they are conveniently not included in the waiting time statistics, so our numbers look good for those who get care but not so good if we look across all the potential patients.

The other problem is the one you mentioned, that establishing the p's in itself can be incorrect, increasing mortality. But, then, our mortality figures are nothing to brag about in comparison with western democracies.
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Old 07-23-2007, 07:43 PM   #15
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Well put, this is exactly what we should strive for. Few of us have a vested interest in the current system, in fact many to most of us thoroughly dislike much of it.

This is exactly why I am watching the MA "universal care" rollout so closely since that system was developed in a bi-partisan way by people who knew both the pros and cons of the Canadian/European experiences as well as the domestic situation. It won't be perfect either, but it could easily be better than what was there before.
Finance Geek -

Being in the industry, I get to see a lot of comments that fly back and forth from agents in the MA area. Here is one that I saw posted recently on one of our discussion boards:

" The Commonwealth Care plan is the subsidized insurance plan for individuals in MA (not to be confused with Commonwealth Choice which is not subsidized). There are four MCO's (managed care organizations) who are in this market and began offering plans for sale on 1/1/07. The state chose them through a bidding process last year and established a 6 month rate review. It is true that 2 out of the 4 MCO plans requested rate increases in excess of what the state wanted to agree to. I don't know where this process stands right now, but I am not surprised to find that the MCO's underpriced the cost of providing medical care when I hear about people who have not been to a doctor in 30 years suddenly getting health insurance.

The carriers who are in Commonwealth Choice just began selling plans on 5/1/07. We won't know whether they are underpriced or what will happen in their first annual review. I think the carriers knew what they were doing a little better in this market, but there was incredible pressure to lower their rates when the first round of bids showed that 'affordable' health plans were not all that affordable. It will be interesting to see what happens a year from now."
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Old 07-23-2007, 08:08 PM   #16
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Agree, but I don't look at it as "imposing" waiting times, but as a result of a finite resource distributed among a fixed demand. If there are p patients, the average procedure time per patient is t, and there are m machines, the average waiting time w per machine in an ideal system without priorities is is w= p*t/m. To decrease w, you can increase m. Well, you can also decrease t through efficiencies or sloppiness but let's say that's fixed.

In a priority system, you have categories of p, p1, p2, ..., pn, so you can vary the w's depending on the priorities. The higher priorities get shorter waiting times but at the expense of the lower priorities, which provides an opportunity for those who want to play with the numbers.

Our system also has priorities, where the last priorities (the uninsured or underinsured) have infiinite waiting times, but they are conveniently not included in the waiting time statistics, so our numbers look good for those who get care but not so good if we look across all the potential patients.

The other problem is the one you mentioned, that establishing the p's in itself can be incorrect, increasing mortality. But, then, our mortality figures are nothing to brag about in comparison with western democracies.
You make good points, but in America, only a small percentage of the uninsured or underinsured populations are in need of non-emergent services that they can't afford.... Therefore, in the USA, it is a a relatively small number of people have to "wait" for care as compared to Canada where EVERYONE has to "wait" their turn for non-emergent services due to IMPOSED waiting times. ...and please don't bring up people waiting for drugs....in Canada, the gov't doesn't cover prescriptions, so many people pay out of pocket for their drugs in Canada just like we do in the USA. The only reason drugs are cheaper in Canada is because they get to buy them cheaper from the USA drug companies than the prices we get in the USA and then Americans subsidize the difference. If it weren't for Americans paying the price, Canada wouldn't have cheap drugs. Rationing is rationing regardless of how it happens, but which is worse?...rationing for EVERYONE or rationing for a relatively small percentage of the population?

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.
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Old 07-23-2007, 08:14 PM   #17
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Agree, but I don't look at it as "imposing" waiting times, but as a result of a finite resource distributed among a fixed demand. If there are p patients, the average procedure time per patient is t, and there are m machines, the average waiting time w per machine in an ideal system without priorities is is w= p*t/m. To decrease w, you can increase m. Well, you can also decrease t through efficiencies or sloppiness but let's say that's fixed.
t is not fixed. There are significant opportunities to decrease t through applying operations management techniques and better design of the processes of care. Here's one example of such an outcome: the wait time for a particular test (elective only) fell from 20 weeks to 3 weeks when the process was redesigned.

Another strategy is to introduce value into a waiting time. For example, two overweight smokers show up for a hip replacement. Mr. A has surgery the next day. Mr. B is is scheduled for surgery in three months, but is immediately enrolled in a prehabilitation program involving exercise, help with smoking cessation, and dietary counselling. Who do you think will have a better outcome?

I am aware of a place in Canada where they tried this, and many of the people who thought they needed hip replacements became so fit and pain free that they ultimately declined the procedure altogether. That, of course, shortened the waiting list for everyone else.

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Our system also has priorities, where the last priorities (the uninsured or underinsured) have infiinite waiting times, but they are conveniently not included in the waiting time statistics, so our numbers look good for those who get care but not so good if we look across all the potential patients.
Unfortunately, information from my colleagues in the US confirms this. Uninsured people with expensive chronic diseases who cannot pay for their care do not get on waiting lists. If their needs are not addressed, complications are not prevented. For example, diabetics who cannot afford meds or foot care will have a higher risk of developing blindness, vascular disease, etc.
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Old 07-23-2007, 08:25 PM   #18
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Another strategy is to introduce value into a waiting time. For example, two overweight smokers show up for a hip replacement. Mr. A has surgery the next day. Mr. B is is scheduled for surgery in three months, but is immediately enrolled in a prehabilitation program involving exercise, help with smoking cessation, and dietary counselling. Who do you think will have a better outcome?
You are so right. But a big problem is that in a system where people don't have to worry about the ultimate cost of their care, they are less motivated to take preventive measures. In America, we are already seeing a huge push by insurance carriers and our own gov't (through HSA tax incentives) to offer incentives for people to get preventive care.
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Old 07-24-2007, 12:36 AM   #19
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In America, we are already seeing a huge push by insurance carriers and our own gov't (through HSA tax incentives) to offer incentives for people to get preventive care.
HSAs don't help the poor, who can't afford to fund their plans with the $1-2500 deductible. ( I like mine though. ) They also don't help the 45 million Americans who are uninsured, many of whom are working class but can't meet the premiums.
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Old 07-24-2007, 07:45 AM   #20
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You make good points, but in America, only a small percentage of the uninsured or underinsured populations are in need of non-emergent services that they can't afford....
I wasn't arguing for or against the Canadian system, don't know much about it. I was just trying to find unbiased figures on the wait times I hear so much about and attempting to make sense of the numbers. You also raise a good point, but is it true that few un/underinsured are in need of non-emergency services they can't afford? I've heard of figures from 20 to 50 million Americans fall into the un/underinsured, let's take the lower figure, 20 million. What's a small percentage (if true)? 10%? 25%? That's 2-5 million. But we're just speculating, I wonder what the true number is.

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Therefore, in the USA, it is a a relatively small number of people have to "wait" for care as compared to Canada where EVERYONE has to "wait" their turn for non-emergent services due to IMPOSED waiting times.
That's not what I hear from Canadians who are in the system. I doubt the Canadian govt says, gee, you need tratment, but you must wait 2 days, or 1 week or whatever because we have to impose this waiting period. I suspect it's more like you need care and based on your condition we will take you right away, in 3 days, in 3 weeks, etc. Do we have a Canadian on this board that can straighten us out?

[...and please don't bring up people waiting for drugs....]
OK, I didn't, nor was I going to.

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The only reason drugs are cheaper in Canada is because they get to buy them cheaper from the USA drug companies than the prices we get in the USA and then Americans subsidize the difference. If it weren't for Americans paying the price, Canada wouldn't have cheap drugs.
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?

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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.
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?

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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 don't buy these type of conspiracy theories... "I don't have the data, but trust me it's there, if only the gummints would let me have it." If anything, I suspect the HMOs and drug companies are the ones cooking the books.

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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.
I bet someone could find a terrible anectdote or two like that about the US system as well.

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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.
I don't know what the solution is. I just think everyone who works or has worked should have affordable health care, and not be denied because of insurance screenings. I don't have these problems, and I don't want any other citizens to have these problems either.
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