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Old 03-08-2009, 02:05 PM   #221
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Has anyone addressed that if "he current American system currently results in groundbreaking advances" where does the world go for that in our system is changed? Sure, there are and will be break troughs but will it be at the same rate?
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Old 03-08-2009, 03:14 PM   #222
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The way I see the Canadian system is that healthcare is treated as a public good, and equity is a fundamental value.
Would you please comment on how Canada handles health care for non-citizens?

Tourists?
Illegal immigrants with $$$? Without $$$?
Folks with $$$ who just want to come and pay for treatment unavailable in their home country?

Are you happy with how Canada handles non-citizens in its health care system and would you recommend the Canadian policies for adoption in the USA?

Thanks!
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Old 03-08-2009, 03:20 PM   #223
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It would seem that way.

I've only spoken with two Canadians on the subject and they were both Canadian citizens on assignment for my former employer MegaCorp here in the States. Their views might not be typical or representive.

They both were highly in favor of the Canadian system. But both felt that having access to USA medical resources (on their own dime and these guys could afford it) was important to them and they'd rather not give it up. I have no clue why they would feel that way. Seeking the best of both worlds perhaps?

Neither seemed to want us to not have what they have, as the Ogden quote would imply. They just wanted our system to still have centers of excellence like Mayo, Cleveland Clinic, etc., and for access to those centers to be available to them on a "money talks" basis.
My quote had bad timing, I was not thinking US and Canada, I was thinking US and US.

BTW, Mayo is in network for me. A number of our lawyers at my old firm used to go there for the executive physical. I question the value. I think they were truly looking for an insurance policy against death.
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Old 03-08-2009, 03:40 PM   #224
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Would you please comment on how Canada handles health care for non-citizens? Tourists? Illegal immigrants with $$$? Without $$$? Folks with $$$ who just want to come and pay for treatment unavailable in their home country?
Noncitizens, and the occasional Canadians who opt out of Medicare and taxes (e.g. Hutterites) are provided with any necessary treatment first, and then billed by the hospital or physician through their insurance company or directly. If they come from the US, the insurer generally laughs and signs the checks as they consider our fees a bargain.

On occasion, a patient is brought here for specialized elective treatment not available in their home country. Under those circumstances the funding arrangements must be worked out before they come here. In a recent case in my own institution, the hospital director had to guarantee that the presence of the patient would not unduly add to wait times for Canadians.

When someone who is not a citizen comes to live in Canada legally, e.g. on a work permit, or is a landed immigrant, their province or territory of residence begins covering their health care (IIRC) within three months of arrival and registration.

Here's an example: Are You Covered? | Manitoba Health | Province of Manitoba

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Are you happy with how Canada handles non-citizens in its health care system?
Having been in exactly that situation myself, yes, I am quite happy with how Canada handles non-citizens. It was one thing I didn't have to worry about and I could get on with my life.

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and would you recommend the Canadian policies for adoption in the USA?
I can't tell you what to do. The US is the most independent society in the world; Canada is more collectivist. The real question is: which solution will work best for your society's value system, and is that value system subject to change? Perhaps the US might become a more collectivist country after a few years of the second Great Depression.
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Old 03-08-2009, 03:40 PM   #225
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As I see it (and please don't shoot the messenger) the current American system currently results in groundbreaking advances, top notch, timely care for people who are well insured, little emphasis on prevention or population health, high overall costs, a large segment of the population who do not have access to healthcare, a high rate of healthcare related bankruptcy, and extreme anxiety among members of this Forum.
One of the most important things in your list of comments is the "little emphasis on prevention or population health." Prevention is a problem when insurers pay by procedures and diagnosis. I have also read that insurers don't care much about prevention because people do not tend to stay with the same insurer for long anyway, with job changes and the like. One of the reasons our VA now has better outcomes is that it changed its attitude on prevention and followup as after all, it is stuck with the same customers for the long haul. So it wants those with diabetes, epilepsy, asthma, etc. taking care of themselves appropriately and it wants to help people lose weight and stop smoking. Not that everyone else doesn't want the same, it is just that the VA will pay for it.



Meadh, what does Canada do to promote population health?
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Old 03-08-2009, 03:54 PM   #226
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I'm not certain that this is a good analogy. In fact, the insurers' profit motive largely explains what happened. They leaned on government to mandate auto insurance, thereby increasing demand for their product. Then, they reneged on the promise they used entice the government to take action, citing yet another excuse for their high rates. This is precisely why I think insurers should not be part of the solution -- they are in it solely to make money for themselves, not to ensure that you or I have adequate health care.

I agree, but we are in a minority, even among democrats. The problem with insurance company competition is that they are competing for the healthiest. You can buy a good low cost non-group plan from a private insurer if you are perfectly healthy and young. They bet that you will not stay with them for long and most don't. They compete to cover large groups where a few large claims aren't going to break the bank, unlike for small groups. And they have lifetime caps so you or your premature infant probably won't cost them more than a million or two anyway.

They don't want the small employers. They don't want the chronically ill. They don't want the old. The model is a cherry picking model where insurance companies make a lot of money. A huge amount of money. The government ends up picking up the tab for the old and disabled. And many fall through cracks.
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Old 03-08-2009, 03:57 PM   #227
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Has anyone addressed that if "the current American system currently results in groundbreaking advances" where does the world go for that in our system is changed?
Hey, isn't that the theme of this book that I had to put a hold on as my library had every issue out?

Just picked up my old Atlas Shrugged book.....

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Old 03-08-2009, 03:57 PM   #228
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When someone who is not a citizen comes to live in Canada legally, e.g. on a work permit, or is a landed immigrant, their province or territory of residence begins covering their health care (IIRC) within three months of arrival and registration.

.
How about long term illegal (undocumented if you wish) folks living in Canada? If someone from that class of people has cancer, how would it be handled?

BTW, I've generally heard good things about the Canadian system. But never having experienced it myself, I'm just curious how it would handle some of our situtions. For example, we tolerate millions of non-citizens being here long term and currently provide education and minimal health care. Including them in a universal medical plan would be an issue in the minds of some people. I'm not sure Canada has to cope with that issue, but I'm curious how you do, if you do.
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Old 03-08-2009, 04:00 PM   #229
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The government ends up picking up the tab for the old and disabled.
I'm curious, who will pick up the tab for the old and disabled in a govt univeral health care plan?
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Old 03-08-2009, 04:03 PM   #230
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Has anyone addressed that if "he current American system currently results in groundbreaking advances" where does the world go for that in our system is changed? Sure, there are and will be break troughs but will it be at the same rate?

Insurance doesn't pay for experimental treatment anyway. That gets done with other money, being parts of studies, etc.

My grandniece was born without much of an intestine. She was on SSI so the government paid for her care, which amounted to well over a million dollars before she died at one year old. They did a surgery on her that had only been done seven times before, with two or three successes. She was not a success. She died a few months later. I had mixed feelings about the whole thing. Should this kind of surgery be even done when the odds are so bad? How long should that poor baby and her parents suffer? The experts really did a pitch for the procedure. In retrospect, all I can say is that I hoped they learned something.
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Old 03-08-2009, 04:06 PM   #231
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I'm curious, who will pick up the tab for the old and disabled in a govt univeral health care plan?
Is this sarcasm? We all pay for it now and we all will pay for it with universal care. You and I contributed to the medical bills of my grandniece.
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Old 03-08-2009, 04:18 PM   #232
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I'm curious, who will pick up the tab for the old and disabled in a govt univeral health care plan?
My fear guess is that the treatment to older people will be greatly limited as cost-benefit analysis is applied in order to keep down the cost for the entire plan. Things like bypasses for 75 year-olds will be considered not worth doing since their life expectancy is lower than say, a 50 year-old.
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Old 03-08-2009, 04:19 PM   #233
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They don't want the chronically ill. They don't want the old. The model is a cherry picking model where insurance companies make a lot of money.
But isn't that problem fixed if everyone is required to have insurance, and ins cos have to take all who apply (as in samclem's outline)?

It would also seem to promote more preventive healthcare approaches, since all the companies would be "stuck" with any/all applicants for as long as the applicant wanted to stay with that company. It might take something to help keep the ins cos focused on long term results though. If they are looking to make this Quarter's numbers look good, preventive techniques are going to get the short end. But again, the govt might specify the minimum preventive techniques that must be covered.

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Old 03-08-2009, 04:26 PM   #234
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Meadh, what does Canada do to promote population health?
For people unfamiliar with population health, here are a few links:

Population health - Wikipedia, the free encyclopedia

Population Health - Public Health Agency of Canada

Canadian Population Health Initiative

Basically, population health aims to improve the overall health of the population, thereby reducing the need for healthcare over time. (An apple a day keeps the doctor away, hence the apple on the PHAC website). In real terms, in Canada this translates into public policy. For example, provincial governments (who fund health care organizations) usually conduct, or cause to be conducted, population health assessments every 5 years or so. This helps to determine where the needs are. They can then incorporate those needs into a set of deliverables for the organizations they fund. In recent years, rather than funding individual hospitals and clinics that may not talk to each other, governments have been amalgamating them into health regions or similar clusters. A health region will be responsible for the health and health care of its entire geographically defined population, so it's in its interest to look at the big picture. Some provincial governments have specific indicators that they require health regions to improve, e.g. the number of diabetics getting screened for eye or kidney problems or the number of kids who get their immunizations on time. Another way to address the determinants of health is to get agencies and ministries to work together (e.g. health, housing, education) on policy making and programs. Also, health systems accreditation (Accreditation Canada) incorporates population health into its standards and now has specific sets of standards aimed at specific populations (e.g. child and youth, older people, mental health population). At the frontlines, care plans designed for patients now usually incorporate secondary prevention measures; for example, a care plan for myocardial infarction may include a stop smoking program, exercise and rehabilitation, and a visit to the psychologist in case of depression; a care plan for acute asthma will include family asthma education.

One further step that I would like to see taken is that the money follows the patient. Currently it's allocated to facilities and programs.
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Old 03-08-2009, 04:33 PM   #235
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Crap, I lost my post with a bad signal. Briefly, I would accept SamClem's solution as a compromise. There are issues and always will be issues. One in enforcement of requiring insurance. Wyden's plan addressed that issue by collecting payments through the tax system, yet still kept insurance companies. Another issue is that the care focus is driven by insurers, so prevention and chronic care may get short shrift as it does now. "What, you check your blood sugar 6 times a day? That isn't usual, the insurance company will only pay for test strips to check two times." Who cares if there is substantial health benefit to increased checking. The other issue is the administrative layer resulting from multiple insurers each with their own paperwork and other requirements. Major PITA for providers. "Now who is your insurer? Lets see, they only pay for this inhaler, not that inhaler."
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Old 03-08-2009, 04:40 PM   #236
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For people unfamiliar with population health, here are a few links:

Population health - Wikipedia, the free encyclopedia

Population Health - Public Health Agency of Canada

Canadian Population Health Initiative

Basically, population health aims to improve the overall health of the population, thereby reducing the need for healthcare over time. (An apple a day keeps the doctor away, hence the apple on the PHAC website). In real terms, in Canada this translates into public policy. For example, provincial governments (who fund health care organizations) usually conduct, or cause to be conducted, population health assessments every 5 years or so. This helps to determine where the needs are. They can then incorporate those needs into a set of deliverables for the organizations they fund. In recent years, rather than funding individual hospitals and clinics that may not talk to each other, governments have been amalgamating them into health regions or similar clusters. A health region will be responsible for the health and health care of its entire geographically defined population, so it's in its interest to look at the big picture. Some provincial governments have specific indicators that they require health regions to improve, e.g. the number of diabetics getting screened for eye or kidney problems or the number of kids who get their immunizations on time. Another way to address the determinants of health is to get agencies and ministries to work together (e.g. health, housing, education) on policy making and programs. Also, health systems accreditation (Accreditation Canada) incorporates population health into its standards and now has specific sets of standards aimed at specific populations (e.g. child and youth, older people, mental health population). At the frontlines, care plans designed for patients now usually incorporate secondary prevention measures; for example, a care plan for myocardial infarction may include a stop smoking program, exercise and rehabilitation, and a visit to the psychologist in case of depression; a care plan for acute asthma will include family asthma education.

One further step that I would like to see taken is that the money follows the patient. Currently it's allocated to facilities and programs.
Great stuff Meadh, thanks. One place where I see we have a big problem with population health is with mental health. I really have seen that in the homeless population and in the young runaway population. They end up hospitalized in emergencies and booted out quickly as no one pays, with no good followup. Some are mentally disabled but don't get classified as such because their care is so sporadic and no one is in charge of seeing if they are eligible for disability. Their drug compliance is poor. For example, Wisconsin charges a $10 copay for their "free" drug program for the very poor. So, you sell you blood. What you are going to buy? Cigarettes or Risperdol? You need the cigarettes.
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Old 03-08-2009, 04:55 PM   #237
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By the way, "break through" discoveries are no longer the sole domain of the US. Western Europe, Russia, France and other places have an equal or better research presence in specific areas than we do. We may be a powerhouse, but it is no longer a one-country world. Even in stem cell research we have fallen behind because of funding and political/ethical issues. Pharmaceutical companies support research and clinical trials which are driven by their commercial interests, and yes, occasionally we get a break through. Universities are weakly funded and now proudly accept drug company support which automatically makes the interpretations hard to assess objectively ("I wonder how many other studies they chose NOT to publish.").

So I am not convinced that research and breakthroughs are necessary a product of our current insurance system. Under a more universal system, the NIH, CDC, etc. could prioritize the research support they grant based on noncommercial factors.
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Old 03-08-2009, 04:55 PM   #238
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Briefly, I would accept SamClem's solution as a compromise. There are issues and always will be issues.
No doubt - the question is which system is likely to have the best outcome overall.
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One in enforcement of requiring insurance. Wyden's plan addressed that issue by collecting payments through the tax system, yet still kept insurance companies.
Maybe I'm being over simplistic here, but I fail to see a problem. Everyone gets a voucher, they are in the system. Period. The vouchers are paid out of the general taxes, which is no different from most programs.

One problem would be getting all people to comply with the preventive care. Not much you can threaten a poor person with. But yet, that is no different today, so that isn't a net negative.


Quote:
Another issue is that the care focus is driven by insurers, so prevention and chronic care may get short shrift as it does now. "What, you check your blood sugar 6 times a day? That isn't usual, the insurance company will only pay for test strips to check two times." Who cares if there is substantial health benefit to increased checking.
I guess that is where the govt would be mandating minimal "best practices". Yes, all sorts of room in there for problems, but wouldn't we have similar problems if it was all govt provided? Or maybe the problems would be from the other end - overpaying for unneeded procedures?


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The other issue is the administrative layer resulting from multiple insurers each with their own paperwork and other requirements. Major PITA for providers. "Now who is your insurer? Lets see, they only pay for this inhaler, not that inhaler."
Much of the paperwork could be standardized. Businesses do this all the time. I don't look to see who manufactured my Thumb/Flash drive before I stick it in the USB port - it's standardized. Yes, ins cos will try to differentiate themselves in some ways, but I would think the majority of costs could fit some standard procedures. I'll bet the Pareto principle applies, 20% of the procedures are responsible for 80% of the cost.

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Old 03-08-2009, 04:57 PM   #239
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The US is the most independent society in the world; Canada is more collectivist. The real question is: which solution will work best for your society's value system, and is that value system subject to change?
Been thinking about Meadbh's statement (above).

Assume we go ahead with a plan for universal coverage. Say it's the plan that would provide Medicare for all, regardless of age. Good. But based on who we are there would be a bunch of interesting questions to be answered.

Like:

Medicare for all would require a chunk of new tax money to pay for it. OK. How would we structure the taxes? Just increase the current Medicare payroll tax? Increase income tax rates? Invent new taxes on citizens? On businesses?

Who would be included? All citizens? Plus folks with greencards? Plus undocumented long term residents (also know as "illegals")? Plus fresh undocumented arrivals? My cousin Kieran living near Dublin?

What would be covered? Who would make the decisions? Would those folks be elected or appointed? With our always rapidly changing outlooks on issues, could/would we have enough policy consistency?

We're having a hard time deciding whether to do it or not (although we did get Medicare going which is covering many). How will we get these details ironed out? Can we trust our form of govt to make decisions many Americans are typically happier making for themselves?
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Old 03-08-2009, 05:00 PM   #240
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How about long term illegal (undocumented if you wish) folks living in Canada? If someone from that class of people has cancer, how would it be handled?

BTW, I've generally heard good things about the Canadian system. But never having experienced it myself, I'm just curious how it would handle some of our situtions. For example, we tolerate millions of non-citizens being here long term and currently provide education and minimal health care. Including them in a universal medical plan would be an issue in the minds of some people. I'm not sure Canada has to cope with that issue, but I'm curious how you do, if you do.
Illegal immigrants are not covered. That can become a serious problem for public health if they have contagious diseases.
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