Asymmetrical Information

First, let me say that I'm very sorry about what happened to your brother.

But I can assure you that if your brother had had that accident in any major Canadian city he would have received the same treatment.

Without question there are problems with the Canadian medical system and -- as is the case in all Westernized countries -- solving them is no easy matter. However, we value human life as much as you do and have highly qualified medical scientists who do everything in their power to save it. As well, parents who come to the bedside of a gravely ill child are not asked to sign financial waivers, something I'm sure your parents could have done without.

Our public health care system is flawed -- no doubt about it but so is yours.

The point isn't, I think, that Canadians would have been left by the road to die. The point is that people tend to urge us to move to single payer because they believe that Americans are left by the road to die, which he's pointing out isn't true. And given that the American system produces things we like, like new drugs and medical equipment, we should think twice before altering it.

Yes, I got your point that kids aren't left to die in the U.S. And frankly, I never thought they were.

What I resent is your correspondent's assertion that such high quality medical care would not likely be available in Canada, lack of MRIs, etc, etc.

For the record this is what was said:

"There is also no doubt in my mind that Adam's death would have come much sooner, and that his treatment would have been far less aggressive and inferior in quality, if this same scenario had played out in a country with a Hillarycare-esque System."

In other words, no one has a health care system as good as the USA.

Much the same kind of story was told by an employee of the BBC concerning his inability to get the absolutely necessary aggresive and immediate treatment for his cancer through the NHI scheme. He also had spent his own money on private health insurance, which did give him access to what was required for his [so-far] successful treatment!

As far as the Canadian health care system goes, you might want to read (Canadian) columnist Mark Steyn's take on its relationship to the Toronto SARS epidemic.

Jim

Uh, joan benz, this comment in particular from the correspondent's message says something interesting, IF true:

To illustrate, I refer you to the 20 MRI's Adam received in his last 13 days. I once read that there are as many MRI instruments in the Washington D.C. area as there are in all of Canada. This may well be a canard, but there is certainly no shortage of anecdotes detailing just how difficult it is for Canadian patients to receive even the most basic of diagnostic tests. The average wait for an MRI is something like 3 months - Adam needed 20 of them in 13 days. Advocates of single payer health care appear to believe that the system which produces the former result is superior to the one that produces the latter.

Population of Canada: About 32 million
Population of Washington, DC: About 572,000

(Sources: CIA World Factbook, "Canada," http://www.cia.gov/cia/publications/factbook/geos/ca.html and AreaConnect, "Washington, DC," http://www.areaconnect.com/population.htm?s=DC)

What the distribution of MRI units looks like in the state of Colorado, where I live, I have no idea. However I know from experience that their existence is not uncommon, nor is a scan hard to get if one is needed.

A quick googling found this:

"There were 53 operating MRI sites in Canada at the end of 1997. There are 1.7 MRI units per 1 million population in Canada, compared with 4.3 per 1 million for a range of comparable European countries, and 9.4 per 1 million for a worldwide sample of similar industrial countries. The survey showed that a minority of sites received any government funding for capital acquisition (23%) or related building costs (19%). A direct government grant to at least partially cover operating costs was available at 42% of sites. The average numbers of examinations performed was 3653 per site per year, with average operating hours of 64 per week, and a throughput of 1.1 examinations per hour. These figures are equivalent to those from sites in other countries."

Interestingly enough, Canada spends more than most countries on medical care and still gets abysmal results.
The figures on this page:
http://oldfraser.lexi.net/publications/forum/2001/11/section_12.html
indicate that as far as MRIs per capita go, Canada is in the same league as the Czech Republic, and in terms of CT Scanners, Canada measures up nicely compared to...Greece.

I can't speak to everywhere in Canada, but there is no way that a similar level of treatment would have been received in Saskatchewan. I believe we currently have two MRIs in the entire province (pop. 1 million, spread over a very large area). There were concerns not long ago that we may soon have no neurosurgeons (I think we had three at the time).

Medical care is a provincial responsibility and can vary greatly across the country, but I would b very surpised if the level of care described would be available anywhere outside of one or two of our largest cities, probably not even there.

From my experience, routine issues are generally handled well and quickly in the Canadian medical system, but surgeons, specialists and specialized equipment are in short supply. Antibiotics and stitches, we're covered. Hip replacements, MRIs or SARs, not so much. Lots of Canadians travel to the US for specialized treatment. Not too many Americans heading north.

I lived in Canada off and on for several years, and after a while one becomes tired of the fact that in any conversation with a new Canadian acquaintance, one is regaled with tales of the horrors of American health care vs the infinitely superior Canadian system. (Usual within the first hour's acquaintance, can't you people talk about anything else for crying out loud?)

So, well, here's a few examples from my experience with my own acquaintances.

(1) A distant cousin, female, presents at the emergency room in Toronto hemorrhaging badly in a gynecological emergency. They packed her up, put her on progesterone to induce vaginal contractions and gave her an emergency appointment with an OB/GYN. Thanks to the emergency nature of it, the appointment was only six weeks later. BY comparison -- I did my PhD in Duke Medical School -- in a US hospital, she would have likely seen the OB/GYN resident or attending before she got her feet out of the stirrups.

(2) a co-worker who had a degenerative eye condition. Immediate surgery would prevent any further degeneration, but was not classified as "emergency" surgery ... and was thus scheduled for three years in the future. Luckily, we both worked for IBM; my friend contrived to become an employee of the US division, and was then able to use the US health system -- and had his surgery three weeks later. He might have gotten quicker surgery than three years later in Canada -- but only after the degeneration progressed to the point that his eyesight was severely compromised.

(3) I had a minor eye problem. I was a US employee in Canada on temporary duty; as such I was a paying customer. I saw a doctor in 24 hours. A Canadian would have seen a doctor within the year.

The point is that Canadians, for whatever reason, are massively uninformed about just how badly they're treated by their health-care system.

This may seem like a quibble, but I looked at a map once. Actually, lots of times. It appears that the number of serious medical facilities in Canada should be considered as per zillion square miles, not population.
Jeez, what a lot of country.

In other words, no one has a health care system as good as the USA.

Damn straight. When people are given the freedom to strive, succeed and take on the responsibility of buying the best insurance for themselves - and in turn, doctors and hospitals are given the maximum amount of market and career flexibility - the best results will occur. Always. Try to give everyone something by taking away from others, and everyone will be left with little.

The socialists had the 20th Century to demonstrate and they failed; enough of the utopia rubbish, already!

Having grown up in St. Louis, I can say that there happens to be an extremely large and well-funded medical community there. Barnes Hospital-Jewish-Children's hospital (yes, that's the real name, from a three-way mergers of Barnes, Jewish, and Children's hospitals) is affiliated with Washington University, one of the top 5 medical schools in the US. Also, there are lots of first-rate private health care facilities throughout the St. Louis region.

Health care services available in the US are generally unparalleled in quality. For acute traumas like the one described in the post, there is no better place in the world--and no one will be turned away. Where the US health care system suffers, however, is in preventative medicine. The fact that many people do not have insurance that covers more basic services means that we end up incurring higher costs through visits to emergency rooms for conditions that might have been treated more effectively and more cheaply had they been diagnosed during a routine visit (which people who don't have health insurance don't often do). There are millions of instances every year of people visiting the emergency room for non-emergency conditions; they can't be turned away, and the costs of treating them are outrageously high.

Taxpayers (or a risk-sharing pool of insurers) will cover that $230,000 bill. We may have the best medical care available anywhere, but it ain't free. Health care services (it total) are on the order of a trillion dollars a year. Getting more uninsured Americans better preventive medicine would lower our overall costs tremendously.

Canada's size is somewhat misleading, the vast majority of the population is very concentrated. Something like 90% of the population of Canada lives within 200 miles of the US border, because the population is highly concentrated in a few urban centers. Even more so, Canada's urban centers are, on average, more densely populated than US urban centers. Canada has a lot of area but most of it is very, very sparesely inhabitated. The same is true of Australia by the way (which is one of the most urbanized countries in the world). The image of rustic, rural, "outdoorsman" Canadians (or Austrialians) is highly inaccurate.

Anywho, another thing to consider is that America's higher number of MRI machines and higher rate of MRI purchases means that America has, on average, many more newer MRI machines than Canada. The same likely applies to CT machines and other similar equipment. Knowing a little bit about the rate of advancement in MRI technology I'd have to say that almost certainly means that those newer machines are also better than older machines.

Getting more uninsured Americans better preventive medicine would lower our overall costs tremendously.

Agreed. That's where a system similar to Singapore's medical account system would help tremendously. In addition, it would reduce the incidence of 3rd party payments, which is directly correlated with cost.

I was recently hospitialized for acute appendicitis. I arrived at the ER at about 7 AM with severe stomach pains. By mid-afternoon, a battery of tests had been run to diagnose the problem, and by 8 PM the surgery was completed. The appendix had not burst yet, but would have done so without action being taken. I have no doubt whatsoever that under the Canadian or U.K. systems, with routine six-month waits for medical care, I'd be dead. This is one reason why I am so vehement in opposing any transition to communist medicine. Those who advocate it are directly threatening my life, in this and other ways.

- Firebug

I was previously ignorant of Singapore's Health Care savings plan, I was curious by mention of it so I googled it. It seems to be somewhat like a Health Care IRA. I think it's a good idea, there's no reason every nation shouldn't have such a system. One thing I'd also like to see is a health-care credit card. It would work just like a regular credit card except you can only use it for health care. Because health care is a completely different kind of expenditure than, say, CDs, movie tickets, clothing, etc. (i.e. all the things people buy with regular credit cards) it should be, at least I think, easier to get approval for decently high limits and the interest rates should be lower. If a medical credit card was easier to get and had lower rates it would probably encourage people to seek preventative care more readily, even if they couldn't really "afford it" just then. That's my theory anyway.

Is it me, or are a lot--if not most--of the testimonials we see for single payer health care nations from people who are not those who have had a medical crisis (and therefore are by definition *not* those who have actually had to deal with the system first hand and intensely), but who are offended at the idea that someone might be unable to get medical care as a matter of right? For that matter, I also seem to notice that the foremost testimonials regarding American health care are from people grateful for fast--though not necessarily fully paid for--access that made a difference in their situations.

Just an impression.

The fundamental problem with our health care system is exhibited in this story:

A patient that required $230,000 in care paid $0.

Such freeriding undoubtably puts a strain on our health care system. It makes no sense that the hospitals and health care apparatus are forced to pick up the cost for the uninsured. That is exactly why health care costs have skyrocketed in the U.S. It seems to me that government-financed health care, which solves the public goods probelm, is a sensible solution.

I'm not sure why so many here believe the non-sequitor that such a system would lead to a devastation of the U.S. health care system. On the contrary, it seems to me that since no one would be able to free-ride, care would be less costly and more accessible.

A few years ago Tom Green had his cancer treated in the United States. Why didn't he go home to Canada for treatment?

There are always going to be "free-riders" though. Simply because not all can afford to pay. Even if it's nationalized health care, there are large numbers of people who will have their care financed by others through dramatically higher taxes. I get so angry when Europeans talk about free health care because there's no such thing. Someone somewhere is paying. Socialized care is not where we want to head. I believe that the government should take up the slack and cover those who are uninsured, but I don't think the government should regulate the entire health care industry. Indeed, I have real issues with the federal government intervening into something as personal as my body.

A health care credit card for the uninsured would be a good idea. I'm not too knowledgeable about the health care industry so forgive me if I sound stupid, but I have never understood why covering the estimated 45million (I always hear different numbers though) uninsured Americans will supposedly cost billions. How would it be even possible for each uninsured person to drive up a more than $1 million bill (barring some sort of debilitating disease or accident).

Tell your freeloading parents to pay the damned bill. Adam wasn't my son - why should his care come out of my insurance premiums and tax money?

John, that's an incredibly rude thing to say to someone who's lost a family member tragically. And the expenses don't come out of just your insurance premiums and tax money, it comes out of everyone's.

Indeed, he should have been assured treatment regardless of ability to pay simply because he is/was a human being.

What if the hospital had refused to cover the costs? What if they had given him zero or minimal treatment because there was no one to pay? The whole story of Adams treatment doesn't really support the notion that private health is equitable, Adam simply got lucky that he ended up in a charitably minded hospital.

Sadly, though public health systems also have their problems too. Often the problems are brought on by government under-funding, but that is not an easy problem to solve either.

A few points:
1)My heart goes out to the writer of this email. However, ultimately he is using his grief to attack a system that he knows very little about.

2)A friend is a doctor who was trained and practised in Canada and is now pratising in the States..he has said that he can get an MRI for a patient if the patient needs one in Canada. The average waiting time doesn't mean that everyone is put at the end of the queue. People are put in priority sequence based on the seriousness of the injury. He also notes that there are some differences in the level of technology used in the hospital he worked at in Canada and the one he knows work at in the U.S. (both are top-rated) but the difference is that some of the stuff is more advanced in the American hospital and in other areas it's more advanced in the Canadian hospital that he used to work at. In other words, both have the latest medical devices/computers/etc. the money was just spent with different priorities in mind.

3)I've seen many reports that note that Canada's system is inefficient as compared to other European systems. Part of the reason is that Canada has one of the only single-payer health care system which doesn't impose any kind of "cost-benefit" restrictions on services. For example, you can't get a heart transplant in England if you are over 50. The reason is that someone determined that the money would be "wasted" because it would essentially be too much to spend with little benefit in return. Canada has no such restrictions and we essentially allow the money to be "wasted", which makes the Canadian system look bad when comparing costs and benefits to other single-payer systems.

4)Again my condolences, but this kind of story illustrates to me why health care reform will never happen in this country. Rather than looking at big picture items such as the fact that Canada spends less on health care, covers everyone and Canadians have a higher life expectancy and lower infant mortality rate, people focus on the one or two individual stories where someone received life saving care that they DON'T THINK they would have gotten under a single payer system in the U.S. The Canadian system is not a perfect system, but it is better than the one that the U.S. has on the whole..and I'm someone who has lived on both sides of the border and experienced both systems.

Yes, Canada might have fewer MRI machines than Washington, D.C., but MRI machines alone don't quantify the quality of a health care system. It is so much more than that. It is also valid to state that, yes, some people, due to the circumstances that they are put in by act of God, will live under a U.S. system but die under a Canadian system. But the numbers say that on the whole, people are healthier in Canada. More people will live under a Canadian system when they would have died under the American system than the other way around.

I guess it's necessary to be a curr and point this out: this is just a variant of the Limbaugh's "why, if you're poor and really need medical care, you can go to the hospital and give them a fake name" line. Sympathies.

Back in January, Forbes published a brief blurb on a study by Canadians that under their single payer health care system they actually paid more for prescription drugs than patients in the United States. The reason? Lack of generic drugs and lack of competition.

I googled the study cited by the article, including additional research on the topic -- you can find the links here: http://yourword.blogspot.com/2003_01_19_yourword_archive.html#87999347

Joan Benz you can go on with your anecdotal bull about how single payer systems work, but the facts don't support you. In fact, a Wharton economist named Patricia Danzon (linked in the above URL) found that not just Canada's but all single payer systems cost more than the US's. Put that in your pipe and smoke it.

whoops - looks like the link on my page to Danzon's senate testimony is now stale. You can find her home page here: http://hc.wharton.upenn.edu/danzon/index.htm

As well as a paper written in 2000 that contains similar conclusions that were in her June 2000 Senate testimony: http://hc.wharton.upenn.edu/danzon/PDF%20Files/CrossNational2000.pdf

On a related note, this wonderful little Washington Monthly article hasn't gotten much attention. Short summary: Costa Rica spends a twentieth of what we do on each person for health care, yet has virtually the same life expectancy.

Lots of interesting ideas for shifting resources from treatment to prevention and lifestyle stuff.

I must express first sympathy for this man's story, and second, mild horror that people are referring to the *average* wait for MRI or surgical procedures as if it was a good way of estimating the likely wait of an emergency case.

"In fact, a Wharton economist named Patricia Danzon (linked in the above URL) found that not just Canada's but all single payer systems cost more than the US's."

Except that she doesn't; she says all single payer systems pay more for prescription drugs than the US. Big difference.

Greetings,
Having lived under both systems, I can say I appcte the medicine plan in Spain, much more than in the U.S.

I've paid for insurance policies in the States, been covered by my employers, and even paid for a private insurance policy for my family...and in the end of the day the system we always end up using is the State run one here in Spain. I know you hear scary stories about long-wait times, etc., but that's only happened once to us...a non-life threatening operation (my wife wanted an operation on her vericose veins, and which she had to wait for three months). At anytime that we want to take the children to the doctor, we just go, and are seen in the act. If medications are subscribed, and if we've been to the State doctors, then there is a discount in price. Many of the State doctors also have their own private practices as well. In our experience, using private insurance, there are also long waiting periods.

What really turned my eyes was in our last pregnancy, my wife's "water" burst at 21 weeks. None of the private hospitals in our policies (which are maxed expat packages) would admit us. We went to a State hospital, and they got us into a topnotch hospital near our home (sure I had to convince them I didnt want my wife transferred out of town). My wife remained in the hospital for almost a month, in bed, medicated, at 26 weeks we needed to have an emergency birth, and my daughter was born with severe complications due to early birthdate. The State hospital tooks great care of her, where she was for almost 3 months, we spent a lot of nights there, and today she's a healthy 1 1/2 year old, who talks, and runs and plays with her brothers and sisters.

Sure, my view is tainted, but just thot you'd like to hear another side of the story. For the record, I personally have cut out all the private insurance policies, except one from my company since that pays for glasses, etc. My own experience is, it's best to have State supplemented by a private.

Cheers

I was recently hospitialized for acute appendicitis ... I have no doubt whatsoever that under the Canadian or U.K. systems, with routine six-month waits for medical care, I'd be dead.

I must say that this is utter nonsense. Having had an appendectomy myself under the NHS in the UK. The time elapsed from waking up in pain at 3am on a Sunday morning, to waking up in recovery was a fraction over 16 hours - that was on a Sunday and included the 12 hours I waited until the pain became unbearable and was obviously more than something I had eaten. I saw my Doctor at 3.30pm, was in hospital at 4pm and in the OR by 6.30pm.

The problem isn't the emergency treatment, its the wait for non-life threatening treatments such as hip replacements or bypass surgery which is the scandal. Of course, anybody is free to pay to queue jump. The UK has a deeply flawed medical service but there's no need to make up stories about it.

One question from the original anecdote - had the family signed the financial responsbility paperwork, I assume they would now have to pay the $230,000 - at the end of the day, that money will have to come from somewhere.

Listen folks, as I stated in my first post, the Canadian health care system is not perfect. I know there are things that are better about the US system and things that are better about the Canadian one.

What I object to is people who are so blinded by ideology that they seize on any case to prove it is justification for their point of view.

As others have pointed out if you have appendicitis in Canada you get operated on right away. And if you want anecdotes about appendicitis, here's one. A former colleague was on a camping trip in the US, came down with appendicitis, had a botched emergency operation and ended up having to undergo months of treatment and extra surgery in Canada as a result. Is this an indictment of the entire US medical system? No, it's an indictment of one doctor.

And yes, many Canadians do go to the US for cutting edge cancer treatments because in many cases the US is the best in the world. But to take another example many Americans come to the Schuldice clinic in Toronto for hernia operations because it's the best in the world.

As for MRIs, access is much more limited in Cnada than the States, and yes that is wrong, but we are aware of the problem and trying to fix it.

As for Mark Steyn's piece on SARS, he was way out in right field on that one. I like Steyn most of the time but blaming "socialized" medicine for dotors failure to immediately diagnose a new disease is just plain dumb. Mistakes are made on both sides of the border, and there's zero evidence that more happen in Canada.

Don't you think if one system of medicine were so obviously superior to the other, that we wouldn't all opt for the better system? This is a very complicated question. There are advantages and disadvantages with both systems and there is no simple answer.

Listen folks, as I stated in my first post, the Canadian health care system is not perfect. I know there are things that are better about the US system and things that are better about the Canadian one.

What I object to is people who are so blinded by ideology that they seize on any case to prove it is justification for their point of view.

As others have pointed out if you have appendicitis in Canada you get operated on right away. And if you want anecdotes about appendicitis, here's one. A former colleague was on a camping trip in the US, came down with appendicitis, had a botched emergency operation and ended up having to undergo months of treatment and extra surgery in Canada as a result. Is this an indictment of the entire US medical system? No, it's an indictment of one doctor.

And yes, many Canadians do go to the US for cutting edge cancer treatments because in many cases the US is the best in the world. But to take another example many Americans come to the Schuldice clinic in Toronto for hernia operations because it's the best in the world.

As for MRIs, access is much more limited in Cnada than the States, and yes that is wrong, but we are aware of the problem and trying to fix it.

As for Mark Steyn's piece on SARS, he was way out in right field on that one. I like Steyn most of the time but blaming "socialized" medicine for dotors failure to immediately diagnose a new disease is just plain dumb. Mistakes are made on both sides of the border, and there's zero evidence that more happen in Canada.

Don't you think if one system of medicine were so obviously superior to the other, that we wouldn't all opt for the better system? This is a very complicated question. There are advantages and disadvantages with both systems and there is no simple answer.

When my son was ten, he had unexplained pains in his left leg which almost kept him from walking.
Among the diagnostic techniques used was the MRI. We got it as soon as the doctor ordered it.
At that time, the pain was a mystery. There were no indications from blood studies, or conventional x-rays, or any other method of diagnosis.
It turned out to be a minor problem, easily fixed.
The question I have is whether an unexplained pain in the leg of an active ten-year-old would have been a priority. We didn't know at the time what it might be, and early detection is vital.
People seem to be making the assumption that early detection is cheap. Not if the first attempt to figure something out fails. After that, it gets expensive.

I was in Canada on vacation in 2000. While watching television I saw an interview with the most recent ex-Minister of Health (or whatever it is called there). Among other terrifying things, he said that a woman *with a lump* would wait two or more months for a mammogramn in many cases. When asked by the interviewer if that didn't mean more women would die, he said, "Yes. It's cheaper." Having just had a standard *screening* mammogramn (wait time, two weeks, and that was more my scedule than theirs) I was appalled. I wrote down as much as I could after that. It didn't get any better.

Oh, for Gawd's sake Gail, your comments ring about as true as a Jayson Blair story in the NYT.

Healthcare is a major story here. If any ex-minister made such a stupid remark we would have all heard it over and over and over again.

Next time when you write everything down, be sure to get the name. It's a crucial factor.

A couple of people have mentioned that Adam's lack of insurance and his parents' refusal to sign for his medical bills left other people holding the bag for the $230,000. If he had had insurance, other people would have had to pay around $229,000 of it anyway: since he'd only been out of college a short while, and uninsured for six months, he wouldn't likely have paid much more than $1000 in premiums before he was run over if he had been insured.

The whole point of medical insurance is to spread the costs around. My brother had a brain tumor removed the day after Christmas. I assume that cost far more than all the health insurance premiums he's paid in his life (he's 52). I on the other hand have paid in far more in premiums than I've ever gotten back in health care. As I said, that's how insurance works.

Perhaps Adam's parents should have paid the whole bill, though it's a lot to ask. Who really should have paid is the woman who ran over him. Of course, she should also be in jail for driving around with forged auto insurance papers, and that would make it impossible to earn the money to pay the bill.

Another problem no one has mentioned is that the number of 'free riders' increases premiums for those who do have insurance, which then increases the incentive for those who are (e.g.) unemployed or self-employed to go without. It's a vicious circle. I doubt that national health care would help. Medical savings plans might.

Jane,

Come on ! As you know full well, a single data point, regardless of how wrenching the story, does not a statistical analysis make. A single data point also rarely proves anything, even if the storytelling is therapeutical for the writer.

I'm certain a lot us could trot out episodes when we, in fact, "had a loved one in desperate need of advanced medical care," just like the appendicitis story immediately above. In my family's case, the conclusions drawn would be just the opposite of the bike story. But as unfortunate as the bike story is, it's no more than cheap theatrics to use it to try and prove a point about health care. Given the writer's comments about 'Hillarycare-esque' blah blah blah, his political leanings are pretty clear. Making a political point thusly goes beyond cheap theatrics into appalling grandstanding.

Finally, comebacks like ". . . if you had any brains at all . . ." to dsquared, the lone liberal willing to debate your right-wing cadre at length, really diminish your arguments. I'm surprised you allowed it to pass your self-edit function.

With socialized medicine the government is in subtle and not so subtle ways required to treat citizens like a herd of cattle.

The reason is that the budget can be used for many things besides health care. Roads, bridges, sewer construction, etc.

At least with health insurance the insurance company is focused on one mission.

That comment wasn't directed at D^2; by generalizing it, it was supposed to be clear that it was humorous hyperbole, not to be taken to mean that I actually believe the entire European continent to be anencephalic.

The debate is focusing a lot on the US system v. somebody else's system. I don't see that as really being constructive. We have two problems in this country. First, the provision of preventive care to prevent chronic conditions and the provision of affordable drugs. ER care here, going by the testimonials, is obviously good. But that really isn't the issue. The only way I see folks getting the preventive and pharmaceutical services is by government intervention, though I don't know what kind.

Jane,

I owe you an apology. Sorry I missed the humor and took you to task for my mistake. (And, now that I've looked it up, I know a new word in the bargain.)

Cheers,

The problem with socialized care is that instead of the consumer deciding what the trade off is between health care and other goods is that the government decides. It becomes not a personal question but a political one.

The politician must then decide what gets him more votes. An MRI machine or street resurfacing.

Hi, Amitava! =) Completely agree with you on the need to focus on preventive care instead of emergency care, and I KNOW! How often do we agree?

It seems to me like 90% of preventive care can be done by one's self, however. Eat right. Exercise. Brush your teeth. Etc. Those are things that ought to be rewarded.

Except that if you reward good behavior and don't spread around the catastrophic risks, you don't have a workable insurance system. The two things everyone wants from healthcare are diametrically opposed, and it's time to pick one.

It seems that many of you are missing a few points.

I'd be pretty confident that if I got hit by a car or needed an emergency appendectomy, I could get seen right away and taken care of in most countries, regardless of the system they use. But, what about all those "non-emergency" costs that aren't specifically monetary.

When I dislocated my knee, the ER put it back in place, but I did major damage to ligaments, tendons and muscle tissue. This required two seperate surgeries that weren't emergencies. Actually, it was a medical necessity that I wait. The first time, they wanted the swelling to go down and for me to recover from the trauma before operating. The second, they just had to do a "tune-up" as they called it to the ligament. It was still too loose and my knee cap would slide out pretty easily.

I missed a lot of work during that time. Some from recovery, some from physical therapy, but mostly because I was in too much pain to work. It is pretty hard to think clearly when you are stoned on Vicodin. How much work would I have missed in a Canadian type system? What is the dollar value of the pain I was experiencing? How much did my productivity decline while I was at work? How much would all of that be amplified in a government run system?

I might be way off the mark, but it seems to me that there are a lot more costs than just the money.

To second (sort of) Amitava, why does ours always get contrasted to 'theirs' ?

If the question is whether the US health care system needs to be reformed, why would anyone say, "(Insert pitiful socialized system of choice) sucks. Why the hell would we want to go that route ?" Certainly we should just look at our system and decide if it needs reformed. Then discuss the devilish details of how.

If the issue is, yes, the US health care system does in fact need to be reformed; how do we best accomplish that ? Why would anyone say, "(Insert pitiful socialized system of choice) sucks. Why the hell would we want to go that route ?" Certainly we wouldn't want to emulate bad systems when fixing our own.

Are there any systems out there that provide 'better' coverage (i.e. broader, at less cost, better quality of care, etc.) ? Note that these issues do not have to all be found in one superior system. (Yes, we all know ad infinitum about the drawbacks to (insert pitiful socialized system of choice).)

Why not think about cherry picking good bits from here, better bits from there. And if it turns out that the US provides universal coverage at the lowest cost with the highest quality of care, that still doesn't mean that the system couldn't be improved.

Or do all the folks who so vehemently oppose reform really believe that reforming health care is some kind of socialist wedge issue to bring about the USSA ?

Color me puzzled by the resistance to an honest debate of the topic.

Cheers,

I think people compare the systems because generally when we hear an argument about single payer, it's "look how much cheaper it is in X country", which makes it eminently reasonable to compare care between the two countries to ask what the costs of such systems are. Other than a trivial savings on pharmaceutical advertising and sales, amounting to much less than 1% of costs (and which could be achieved by banning pharma advertising), I've seen no evidence that we could reduce costs without reducing access for the majority of Americans who currently have insurance.

I think there is one obvious method to improve US health care: Eliminate employer based health insurance. Employer involvement in health insurance allows substandard service because the patient is not the customer. This is the primary reason for the success of HMO's, and a primary source of patient complaints.

Employers have no business being involved in health care in the first place. The evolution was caused by government trying to get something for nothing, which backfired as usual. We can give employees the tax breaks, or even credits, currently given to the employers.

Once individuals have reestablished control of their own health needs I think we would see other dramatic improvements, including a wider range of health insurance options. My guess is that we would see a general move toward insurance as risk management. This means individuals would pay for base care out of pocket, and insurance would cover operations and catastrophic costs.

One side benefit would be that the damn doctors would reduce the double and triple bookings. That drives me crazy.

I hear a lot about "universal preventative care" and how it's so desired because it's cheaper than the acute care that it "prevents". This is usually stated as an undisputed fact, or even an axiom. However, it's not self-evident to me.

For example, I understand that it is cheaper for my wife to have a yearly mammogram for the rest of her life than to be treated for advance-stage breast cancer. But that doesn't mean it's cheaper for ALL women over a certain age to have government funded yearly mammograms than to treat the breast cancer cases that are not detected early under the current U.S. healthcare system.

Where are the studies showing this? Also, these studies must take into account the increase in the number of unneeded doctor visits that occur when they are "free". In other words, if socialized medicine encourages people with a cold or mild sprain to run down to the clinic when they wouldn't if it wasn't "free", are those costs included in the calculation that universal preventative care is cheaper than acute care? And I don't mean just the one-time cost of the visit, but also the extra strain this puts on the health care system, in general.

The potential supply of quality doctors is not unlimited (especially if their salaries are limited by the government). If you have a larger percentage of doctors dedicated to treating sniffles and removing splinters, how many are left to be brain surgeons and other specialists (a problem I understand the Canadian system has)? How many are left to do research to find new wonder drugs and treatments? How do you quantify the way such a system affects the allocation of doctors? Are these costs reflected in the comparison of "free" preventative vs. acute treatment?

I don't accept that my inability to get a "free" yearly prostate exam is evidence that the U.S. healthcare system is fatally flawed and needs to be redesigned from top to bottom.

Note: I realize all this cold-sounding rhetoric about costs to treat horrible diseases like cancer might sound harsh. My mother has had breast cancer, so I understand the trauma associated with the disease. I didn't start the cost-benefit argument here, the socialists did.

It would be nice if the advocates of central planning in the delivery of health care goods and services would admit that such a regime will be subject to all the limitations of central planning of other types of goods and services, of which there is a mountain of historical evidence. It would also be nice if the people who resist central planning (in my view, rightly) would admit that there are aspects of the U.S. model which mange to combine the worst features of central planning and market-driven systems, and there is room for improvement.

Also, doe it really need to be pointed out that differences in rates of morbidity between two different populations cannot be taken as evidence that one health care delivery system is superior to another? Correlation is not causation, and all that. If the entire Russian male population were to start gaining access to Canadian health care systems at noon today, their life expentacy would still continue to fall well short of Canadian or U.S. males, for the simple fact the quality or availability of one's doctor ain't going to have much impact on somebody who is on an extended suicide mission. Americans, while living healthier lives than Russians, are, on average, the fattest, most sedentary, people on earth, and the quality of one's health care cannot overcome that. Toss in different homicide rates of young males between the U.S. and Canada (ironically, there is evidence that the unparalled expertise of American emergency gunshot wound care has condsiderably narrowed the homicide gap between the U.S. and Canada in the past 10 years), and I'm a little surprised that Canada's life expectancy lead isn't a little larger.

What I don't understand is this "all or nothing" approach which seems to polarise this argument.

In reality most healthcare services are mixed.

Jason McCollough wrote,
Except that she doesn't; she says all single payer systems pay more for prescription drugs than the US. Big difference.

uhhh...how about speaking in English Jason...here's what I read (below), sounds to me like she's arguing that single payer systems result in higher drug prices...what's your dispute?

"Bilateral drug price and quantity indexes, based on comprehensive data for seven countries US, Canada, France, Germany, Italy, Japan and the UK , refute the conventional wisdom that US drug prices are much higher than elsewhere, for Laspeyres US-weighted indexes. Previous drug-price comparisons are biased by unrepresentative samples and unweighted indexes. Quasi-hedonic regression shows that cross-national price differences reflect differences in product characteristics and in their implicit prices, which reflect the regulatory regime. Strict price regulation systematically lowers prices for older molecules and globally diffused molecules. Generic competition lowers prices in less-regulated regimes, which also have more price-elastic demand."

One other thing worth pointing out is the subsidy that the United States is indirectly giving to other countries.

First, in some (probably small) number of the most complicated cases, patients from abroad come to the United States for treatment. This ranges from the wealthy foreign monarch to indigent immigrants and everyone in between. My college roommate was a medical student at college associated with King's County Hospital, the largest hospital in Brooklyn and the one closest to JFK airport. He would often see women from overseas (most commonly from Jamaica and the Dominican Republic) flying into the United States to give birth, then flying home. This effect is substantial in Canada--many people do cross the border (headed South) for medical treatment.

Second, we subsidize the world's health care through our sponsorship of medical research. Our tax dollars fund the university laboratories where a great deal of primary biomedical research is conducted. The market for prescription drugs in the United States--and our patent system--enable drug companies to earn a sufficient return on their research investment that they can continue to develop new compounds in spite being paid much less overseas, or, in the case of certain Indian drug companies, shameless copying. A high percentage of all new drugs are developed in the United States. We also pay for an FDA certification process from which the rest of the world benefits. The same goes for our development and testing of innovative medical devices. Socialized medicine would severely dampen the innovation that presently characterizes American medicine, as the financial incentive to take enormous risks on new drugs and new devices would evaporate.

Sure, Ecuador spends less than we do on health care, with similar life expectancies. But how many people who need heart transplats come from Ecuador to the United States for surgery? How much money did the Ecuadorian taxpayer spend on medical research this year?

We have the best medical care in the world, and we pay a lot for it. (Diane Keaton: "I think this is the best of all possible worlds." Woody Allen: "It's certainly the most expensive." --Love & Death) The question is, can we pay less without making sacrifices (such as the rationing one poster described in England or long delays others have alluded to) that are unacceptable?

Dave O'Neill wrote:

What I don't understand is this "all or nothing" approach which seems to polarise this argument.

In reality most healthcare services are mixed.

It comes from the leftists' attitude that any healthcare system that doesn't provide "free" services to everyone is, by definition, flawed and must be corrected. Healthcare is one of the things people have a "right" to, after all (according to the leftists).

Just listen to the Castro apologists. They always mention Cuba's socialized medicine as one of the triumphs of the communist regime.

You're right that our current system is a mixed system. So, those of us trying to defend the current system aren't being "all-or-nothing". We're trying to protect the baby from going the way of the bath water.

Myself, I'd like to see any reform be along the lines suggested by mj. We should move as much of the decision-making for insurance purchases, etc., directly into the hands of the citizens as possible by making insurance premiums tax-deductible to individuals. Moving it the other way (into the government) is absolutely not the way to go, IMHO.

The reality is that with the exception of Cuba, all the other health systems are mixed. Most European ones cost the user money they have to claim back.

The UK is a bit of an aberation but if you have money you're allowed to get preferential treatment.

I am sympathetic with the idea that Healthcare is a right - availability too good basic care and preventative work is certainly good for an economy. The question lies as to where you draw the lines and for what.

The US, in my admitidly limited experience of it (based on simply trying to get a Doctor while living in California), draws the line a little to close to one extreme for me, whereas the UK, of which I've most experience pulls way way too far the other way.

such as the rationing one poster described in England or long delays others have alluded to

But this is a fallacy, at least in regard of England. If you can afford to pay or carry private additional insurance you don't have to wait.

The choice is yours.

For some reason this point often gets lost in the noise. It would be nice if universal care was perfect, but this is the real world. The important thing, in my opinion, is universal access to a defined level of care, with people having access to anything else they can pay for.

Isn't it ironic that the example use to show how the evul commie Canadian system sucks is one where the no-cost free US system provides adequate care?

Ah, yes, libertarianism, I forgot. That means that if I get free stuff its ok, but if you get free stuff it's evil, right?

I think a lot of people here may have missed the larger point I was trying to make with this story.
The question of quality is surely subject to debate - Canadian doctors are likely just as skilled as those in the US - but in considering quality it is important that we also consider the availability of resources. Socialist systems cause shortages, capitalist systems produce disparities - this is not an indictment of either system, it's simply the nature of the beasts. But shortages can result in disastrous systemic failures in cases where the burden is extremely large.

Let's flesh out the details a little bit:

Imagine you're a doctor treating a patient who has suffered a head trauma. The patient is sedated at the time of treatment, but becomes combative when sedation is removed. His pupils are reactive and he demonstrates response to painful stimuli in all extremities. X-rays reveal no skull damage and preliminary testing rules out hemorrhaging. The true extent of the injury is indeterminate. What's your next step? Do you:

1) Wait 6 hours and reassess
2) Call in a neurological specialist to assess the patient
3) Send the patient for an MRI to clarify to situation.

Based on my conversations with doctors both at the time and subsequently, all three choices are defensible in the situation described above. But all three are not equally available to doctors in socialized and privatized systems. Option 1 is the simplest and cheapest - but 6 hours is a long time for a severely injured patient. If we assume that Sean's basement of the availability of neurologists in Canada is accurate, Option 2 is going to be borderline impossible if the specialist is not available at a moment's notice. Option 3 is obviously the safest route to choose, but if Jimbo's source is to be believed, getting an MRI on short notice is going to be no simple task in a socialized system - especially if there exist other options for the patient at that point in time. What if the nearest MRI is at a hospital 20 miles away? How much additional expense and harm to the patient will be incurred by transporting him? If the need is not clearly demonstrable, would the doctor even be allowed to try?

These are the kinds of options that are available to doctors in the US that simply are not available - or at least not as readily available - in some other countries. These options do not exist in a vacuum, they are the direct result of associating a profit motive with medical treatment.

Imagine the burden a case like this places on a system without the resources available in the US. Adam's case required 43 neurosurgeon man*hours over about 2 weeks time. If there is not an ample supply of neurosurgeons (per Sean E.), this means that a single case like this one could place a tremendous strain on the system as a whole. How many other people were unable to see a neurosurgeon while Adam was in surgery? In the US, this effect gets lost in the noise - the hospital where he was treated had about 10 neurologists on staff, and that's just one of several hospitals in the region. This would likely not be the case if there were only 3 neurologists in the entire state (or province).

There undoubtedly is something to be said for the availability of preventative medicine in other systems. But these systems achieve that by sacrificing their capacity to deal with severe cases (large scale shocks to the system). Perhaps a happy middle-ground exists. But based on what I've seen though, single-payer systems are not the answer.

P.S. to John - I take your point, and had Adam survived we would have likely spent the rest of our lives paying off his medical bills if only to save him from carrying that debt. But I am unaware of any case where the parents of a deceased adult became responsible for the debts incurred by their late offspring. The little actual wealth Adam had accumulated went to settle his other debts - but he had no estate to speak of. I'm sure Visa also considers our parents to be freeloaders, but they have no legal obligation to pay off his credit cards. If this concerns you, take it up with the legal machinations that forced the hospital to treat him in the first place.

I agree with Adam. To be blunt about it, this family ripped off the system. Why the hell shouldn't this middle class family have to pay all or part of this $230,000 bill.Jane, you shouldn't be posting this -you should be reporting these guys to the authorities(glad their son got treatment). Seems to me this family got a big dollop of socialized medicine (courtesy of their dishonesty) then used their experience as an example of the superiority of free market medicine.
I have a news flash for all on this thread. In a truly free market system, the hospital would have every incentive to turn this boy away. Indeed, every day in the US, for-profit hospitals turn away people who can't pay their bill. Those people either go untreated or go to publicly funded hospitals.
If your family had been honest, they would most likely have been driven into bankruptcy by their bill, like many old people who are being driven into bankruptcy by their pharmacuetical bills. Some of them find relief by going to that socialist medical cesspit, Canada, to buy their drugs.

I agree with Adam. To be blunt about it, this family ripped off the system. Why the hell shouldn't this middle class family have to pay all or part of this $230,000 bill.Jane, you shouldn't be posting this -you should be reporting these guys to the authorities(glad their son got treatment). Seems to me this family got a big dollop of socialized medicine (courtesy of their dishonesty) then used their experience as an example of the superiority of free market medicine.
I have a news flash for all on this thread. In a truly free market system, the hospital would have every incentive to turn this boy away. Indeed, every day in the US, for-profit hospitals turn away people who can't pay their bill. Those people either go untreated or go to publicly funded hospitals.
If your family had been honest, they would most likely have been driven into bankruptcy by their bill, like many old people who are being driven into bankruptcy by their pharmacuetical bills. Some of them find relief by going to that socialist medical cesspit, Canada, to buy their drugs.

Since I'm being cited above I thought I should double check my facts. It appears that the news item I was thinking of dates back to 2000, when 2 of our 4 neurosurgeons announced they were leaving the province. More current reports indicate we may have as many as 10 neurologists - not sure of the distinction.

I'm aware of no modern industrial state where parents or other family members are held legally responsible for the debts of 23-year old adults. Is there something I'm missing?

"I have a news flash for all on this thread. In a truly free market system, the hospital would have every incentive to turn this boy away."

I thought that was the point - that the US system is not a truly free market system and that the uninsured are not completely hung out to dry.

"...like many old people who are being driven into bankruptcy by their pharmacuetical bills. Some of them find relief by going to that socialist medical cesspit, Canada, to buy their drugs."

As Jane has noted in several places, the availability cheaper drugs in Canada is not necessarily a good thing and may not be sustainable if the US implemented a similar policy. Personally, I would be in favour of some government support for pharmaceutical bills for the very poor - I thought the US already had a system like that in place.

Jane,
What you are missing is my point. This family received a big dollop of socialized medical careCanada style, then went around praising the US system.Suppose they had been honest, and the hospital turned them away.I guess you would not have published THAT story. Well, THAT kind of story happens a lot.
Unfortunately, your story proves that you have to be rich, insured, or dishonest to be assured of good heath care in the US-which was probably not your point.

Shuan, those are the stories I'm asking for. I've now posted twice, begging people to send me stories on how they got turned away. So far, no takers. Anecdotal evidence is not data, of course, but I'm so far publishing only what I've gotten, which is that the US system, as currently configured, works.

There is some confusion on this thread about terms like cost, and socialized medicine.

-- Things are not cost free just because you force someone else to pay for them. If we force down doctor salaries, we are not lowering economic costs; we are forcing doctors to pay them. Doctors who donate their time are shouldering the cost themselves; this does not mean there is no cost. Over the long run, lowering doctors salaries tends to produce, either fewer doctors, or fewer doctor hours with the same number of hours. (Although there is an argument to be made that the AMA cartel is artificially raising medical salaries, so there's some room to force them lower, I think it's unlikely given the massive buyer power HMO's currently have.) So the cost we force them to pay eventually comes back to us in the form of rationing.

-- Socialized medicine is a particular thing. It is when the government pays for medical treatment, and levies taxes to pay for the expense. It is not when a corporation spreads the cost of non-payment over all its customers, which all corporations do. That's known as "allowance for bad debts", and it's an item on every corporate account. We don't have "socialized department stores" because Macy's covers its debt defaults and shoplifting losses out of the money I spend there.

Actually, the family didn't receive it, the dead man (Adam) did. I agree that he ripped off the system by spending his money on other things and not buying insurance. But it's a little late to get the money back from him. And in any case, he ripped off the system for $1,000 or so. As I've written above, even if he had had insurance, as he certainly should have, other insured people would have been left holding the bag for around $229,000. That's how insurance works.

Sorry, my last comment was addressed to Shuan Rose, not Jane Galt: her comment slipped in while I was writing mine.

Shaun,

Let me see if I can break down your complaints. Please tell me if I mischaracterize:

1) You accuse Jane of misconduct for failing to report my family and me to the authorities
2) You accuse Jane of hypothetically scuttling a hypothetical story which would make the opposite point
3) You accuse my family of dishonesty in our dealings with the hospital
4) You condemn my praise of a system my family had cheated

I don't want to put words in Jane mouth, but:

1) Please cite the specific legal wrongdoing you see in the details recounted above. I had assumed that since neither the hospital nor Medicaid (through whom it is likely a portion of the bills were covered) has sought to take action against us that they saw no evidence of such. I can only guess that Jane made the same assumption.

2) I don't see how Jane could have been more explicit in actively seeking cases like the nebulous ones you cite (i.e. "Come on, my pinkish pals! Flood me with horror stories. I promise I'll post them"). If you have such a story, please share it with us.

3) Perhaps I could have been more clear in indicating that the hospital was well aware of the financial risks being taken, but I'm not sure how since I clearly stated that the hospital was aware that Adam was uninsured and no one had claimed responsibility for the costs before or during treatment. Please point out exactly what action or omission you see as being dishonest.

4) As I hope I clarified in my post above, I was more interested in pointing out the level of care available, even to the uninsured, in the US health care system. I detailed just how extensive this care was in my original letter. I have seen nothing presented here which would clearly contradict my original belief that this level of care would be either unavailable or extremely scarce under the types of single payer systems currently proposed in the US and in place elsewhere. I consider that praiseworthy. And since my only acts of advocacy for this system have been the original letter (which originated as a private correspondence, though I am pleased that Jane felt it worth publishing) and the subsequent 2 comments (this one included), I hardly think I could be said to have "[gone] around praising the US system".

Furthermore:

"Suppose they had been honest, and the hospital turned them away."

And if things were different, they wouldn't be the same. If it had been necessary, my family and I would have gladly taken on the burden of the cost. You are correct that it would have bankrupted us. But I also consider it praiseworthy of the system that things did not pan out that way. Certainly we were lucky, but I encountered nothing during the treatment to indicate the handling of our case was anything but routine for the hospital.

One last thing:

I find it awfully rich of you to accuse a complete stranger of being a liar, a cheat, and a hypocrite based on a few hundred words reproduced on the internet. The words I would normally use in response to these accusations have no place on a family blog. So I'll simply say that I disagree.

Matt:

"In fact, a Wharton economist named Patricia Danzon (linked in the above URL) found that not just Canada's but all single payer systems cost more than the US's."

"Bilateral drug price and quantity indexes, based on comprehensive data for seven countries US, Canada, France, Germany, Italy, Japan and the UK , refute the conventional wisdom that US drug prices are much higher than elsewhere, for Laspeyres US-weighted indexes."

These two statements aren't equivalent.

Jason:

I would just like to say that personally, I am perfectly happy to donate my share of tax dollars towards your brother's medical bill. It may be that something like that happens to me someday, and I'm reassured to know I can count on the best treatment the US has to offer.

What many of you who accuse his family of irresponsibility are missing something: Jason and his parents have spent (and will continue to spend) their lives paying taxes, and I doubt they'll personally see the benefit from a single penny. That's the socialist aspect of our system, already nicely in place. A portion of my paycheck every two weeks goes into the government's coffers, and hopefully a few cents make it safely back out to aid the life struggle of an indigent child in an ER somewhere because of a car accident.

What Jane is saying (and many of us agree) is that what we have now is quite socialized enough, thank you very much. We have enough free market to encourage lots of innovation and technology and excellence, and enough socialized healthcare to keep the market monster from eating the children.

In defense of the socialists, Jane, I don't think anybody who's ever lost a child because of the inability to get healthcare is likely to be a reader of your blog. Just a hunch. *shrug* But it would be nice if someone knew some social workers or clinic workers who knew about such things? Still, not holding my breath... if I were out helping people, I wouldn't have time to sit here and make comments. :)

Jason said, These two statements aren't equivalent.

Why? Because I said all and she specifically cited 7 countries? Would you care to show me a single-payer system where prescription drugs are cheaper?

You can split hairs on superficial attributes all you want -- but it doesn't change the basic economic argument that single payer systems aren't cheaper.

I was recently hospitalised for acute appendicitis. I arrived at the ER at about 7 AM with severe stomach pains. By mid-afternoon, a battery of tests had been run to diagnose the problem, and by 8 PM the surgery was completed. The appendix had not burst yet, but would have done so without action being taken. I have no doubt whatsoever that under the Canadian or U.K. systems, with routine six-month waits for medical care, I'd be dead.

A couple of years ago I had an identical experience. I presented to a public hospital (weirdly enough) at 08:00 and by 15:00 the appendix had been removed. While we do have universal health insurance we don't have the level of bureaucracy the Canadian and UK systems seem to suffer. it is possible to run inversal health insurance and give treating doctors considerably greater than an HMO or a governmental bureaucracy would give them.

I was admitted as a public patient. I was treated by one of Sydney's better surgeons. The hospital charge was zero although of course I pay the Medicare levy of 1% of income like everyone else.

Broadly, I suspect every Western medical system provides roughly similar care. I suspect that anyone from Country X has horror stories to tell about Country Y and that the stories tend to reflect the teller's politics as much as anything else.

You guys keep talking about great ER experiences. The ER isn't the issue though, as I keep saying. It's access to preventive care and drugs. I don't have any stories because, frankly, I don't know any needy people. I did have this friend who was a highly paid IT worker. Just before he was laid off he was diagnosed with Chrone's disease and some muscle disorders. The only way he got the care he needed to remain healthy was that he was by borrowing against his 401(k), after depleting his savings, to pay for his COBRA and physical therapy. He got a job two years later. Happy ending. But what if he were a janitor? Screwed.

Repeating happy endings about an ER experience does not make Jane's point.

"Would you care to show me a single-payer system where prescription drugs are cheaper?"

She says prescription drugs in single-payer systems are more expensive. She does *not* say that "single payer systems are more expensive." Prescription drugs are only 10-15% of medical spending, after all.

Did it ever occur to anyone that the kind of people most likely to "slip thought cracks" of our medical system don’t have a computer at home to read Jane's blog daily? It might interest you to know there is a very substantial cross section of Americans who have never used a computer. But I would venture a guess that emergency care denied to people who can't pay is the very rare exception.

What ticks me off is the absurd hoops you have to jump thought to get simple medications. Why can't the rules be changed so that physicians assistants and nurse practitioners can offer care with more autonomy from MD's? I mean I have a cold so in order to get a script for some drugs that shouldn't be that heavily regulated in the first place, I have to go to the doctors office, sit in a crowded room with a bunch of sick people and pay an outrageous fee to get a simple script written. That's just plain stupid.

What I would like to see is some kind of single payer system for catastrophic / emergency care (since that what we have right now really when you think about it). High deductible, only kicks in when things get scary expensive. Then have a second layer where you join groups akin to credit unions who offer a range of insurance plans so that you can actually compare apples to apples between providers and shop around, and then have a network of inexpensive providers staffed by physicians assistants and nurse practitioners who can write scripts and act as the front line for less urgent care and who can see people on a walk-in basis. Augment the system with a government private partnership plan for the indigent and savings accounts and specialty plans for kids and seniors and wha da, you're done.

Now who wants to talk about energy policy?

The reason you won't get any stories about emergency patients being turned away is because they will NOT be turned away. The hospitals are required to atleast stabilize the patient before they transfer them to a public hospital. It has something to do with law and morals and hippocratic oaths.

Besides the best emergency / trauma hospitals are public hospitals.

I'm curious Rick DeMent just what prescription it is you need for a cold.

Many people forget that a significant portion of the high cost of healthcare in the United States is a direct result of the extent of government regulation of the healthcare industry. Doctors and hospitals have huge compliance costs in government and insurance paperwork. Funds spent employing an army of paperwork specialists could be spent on doctors, nurses and equipment absent this huge compliance burden, which is due in large part to Medicaid/Medicare. A significant factor in the high cost of prescription drugs and new medical equipment, including prothestics, is the outlandishly expensive and slow process of FDA approval. We'll never know how many people have died for lack of a new medical technology that was mired in the FDA approval process. We'll never know how many medical technologies were never even developed because they could not be expected to recoup the cost of FDA approval.

Rick DeMent: Did it ever occur to anyone that the kind of people most likely to "slip thought cracks" of our medical system don’t have a computer at home to read Jane's blog daily?

*politely raises hand* Yes, there were a few of us that grasped that.

I call allergies a cold, it feels like a cold, it makes my nose run like a....oh sorry. But that's nit picking isn't it? [grin]

I am 62 years old and live in New York. When I began working in 1958 the company I worked for provided Major Medical insurance only. No doctor office visits were covered. Subsequently, I worked for 4 more companies, the last being an airline which was unionized, and in 1970 was covered for office visits for the first time.

These paid visits were limited to 4 per year.

Over time, the union managed to get all office visits covered plus tests, xrays, shots, etc.

In 1958, when I went to the doctor there was the doctor and a receptionist (usually his wife). Now when I go there is an army of workers, all filling out insurance forms.

I believe the answer is to go back to Major Medical only. Cover only hospital bills and surgery along with cancer treatments and the processes leading up to surgery, such as MRI's.

Changing the subject, some major drug companies provide prescription drugs to those who meet an income test.

Another subject, my friend had chest pains and went to a hospital in Brooklyn. He is 68 years old. Within 3 hours a triple by-pass was performed on him.

I have read about heart attack victims in Canada waiting days for surgery. That is if they're lucky enough to find a hospital that will take them. I have read about ambulances going from hospital to hospital.

My daughter had a bad stomach-ache, it was appendicitis. She was diagnosed at 7 AM and operated on at 8 AM.

My other daughter had a gallstone attack. She was operated on the same day.

My 70 year old friend broke her hip. Operated on the same day. I understand that in England they think operating on old people is a waste of money.

I could go on and on. I don't know of anyone who went to a hospital and wasn't taken care of, if not immediately then within a day, whether or not they could pay.

Hillarycare was exposed by the woman who became the Lt.Gov. of New York (I forget her name) Hillarycare was going to assign us a family doctor. Tough if you didn't like the doctor, s/he was yours. And that doctor would be the gate-keeper, deciding if you should or should not see a specialist. Not all doctors are created equal and Americans prefer to choose their own and to get second opinions. Hillarycare didn't provide for that.

Emergency treatment isn't the problem.

The problem is chronic conditions, or long-term care - the majority of medical conditions people have.

People who get stabbed are fine. People with cancer, high blood pressure, arthritis, back problems, asthma, parkinson's, MS, cystic fibrosis, etc etc etc - that's where the problem is.

Cecilia wrote: " Hillarycare was going to assign us a family doctor. Tough if you didn't like the doctor, s/he was yours. And that doctor would be the gate-keeper, deciding if you should or should not see a specialist. Not all doctors are created equal and Americans prefer to choose their own and to get second opinions. Hillarycare didn't provide for that."

HMOs don't provide for that much, either. HMO doctors aren't even the gate-keeper: some non-doctor beancounting flunky at the HMO is.

Having your actual doctor be the gatekeeper would be a vast improvement over HMOs, where the gatekeeper is only faintly interested in the specifics of your case, and is probably more interested in making sure the HMO executives get their bonuses.

I voted against Hillary the first time. If I get my wish, I'll only have to do it one more time, but I'm not holding my breath. Her views on healthcare top my list of reasons.

While I am truly sorry for the devastating pain you and your parents have experienced with the loss of your brother, It seems to me that your family has already benefitted from the single payer system: the taxpayers of the United States.

Your brother had the best care available, your family is not burden with a tremendous financial crisis and that is what I would like all U.S. citizens to have. Single payer healthcare would just be an extension of Medicare, only for all of us, not just our senior citizens.

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