A Model, or a Muddle?

Right-wing lobby groups such as the Fraser Institute and the Business Council on National Issues have been nudging Canadian politicians towards accepting a U.S.-style health-care system, but one recent survey found that 96% of Canadians prefer our system to that of the United States 

"As long as I'm premier, there will be no two-tiered, American-style health system." That's Alberta Premier Ralph Klein speaking. There are few people in Canada who can match Mr. Klein's enthusiasm for free market, profit-based solutions to problems. So, it's a measure of how fearful Canadians are of having a U.S.-style health system that Ralph Klein feels it's necessary to assure voters that he's not going there.

But, what's so awful about American health care? Why don't Canadians want to adopt it?

Essential health care in Canada is funded through taxes and is available to all citizens. In the United States, the system is way more complicated. In general, the American system is a mixture of public (40%) and private (60%) funding. Most full-time employees of companies have private health insurance paid for by their employer. About 85 million Americans buy their health insurance coverage from the federal government. Very poor Americans and low-income retired people are covered by government plans.

But, that leaves a huge number of people not poor enough to qualify for government support but not wealthy enough to afford the cost of health insurance. By 1999, 43.4 million people, or nearly a fifth of the U.S. population under age 65, had no medical insurance; another 29 million were underinsured. These numbers have been rising by about one million annually every year since 1987.

To ensure access to care for these people, there is a network of hospitals and health centres - so-called "safety net hospitals" - that are willing to provide care to anyone in need, regardless of their ability to pay. These healthcare providers receive subsidies to compensate them for their work; some from public sources, some from private, some from donations, and some from fund raising. But, such safety-net hospitals are often for emergencies only. Anything less than an emergency for someone without insurance can mean no treatment at all. So, the medical problem will either go away on its own after a spell of discomfort, or it will get worse. If it gets worse, it may lead to an emergency and admittance to a safety-net hospital. But, by then, it might be too late.

This public/private mixture has produced a system that favours certain groups and works against others. Rich people in the United States can get instant access to the very best medical care available anywhere in the world. Most middle-class Americans have their needs taken care of adequately. However, for Blacks, Hispanics, and poor whites the health-care story is very often an unhappy one.

On average, Black Americans live 6.5 years less than whites, and their children are more than twice as likely to die in infancy. Twice as many Black men die from prostate cancer as white men, and 40% more die from coronary heart disease. Diabetes is 70% more frequent among Blacks and twice as common among Hispanics. High blood pressure and obesity are also more common among Hispanics than among white Americans. For just about every health problem the statistics are similarly unbalanced.

Poverty is largely to blame for this poor health picture. People with little money usually have poor diets and less access to medical care. According to a 1999 Commonwealth Fund study, working Blacks and Hispanics are roughly 20% less likely than whites to have employer-sponsored medical insurance.

But, it seems there is discrimination even among those with proper health insurance. A 1999 study published in the New England Journal of Medicine confirms this. The study shows that heart specialists are 60% less likely to refer a Black woman for a commonly used heart blood vessel test than her white counterpart.

Many doctors in the U.S. look at this picture and shudder. Here's what the 10,000-member Physicians for a National Health Program says is wrong with the current system:

* More than 43 million people do not have any insurance;

* More than 100,000 people lose their health insurance every month;

* The United States is the only industrialized country that doesn't have a health insurance program for everyone;

* More than 25 cents of every health-care dollar is wasted on paperwork, advertising, and multimillion-dollar executive salaries and other things patients neither need nor want;

* People with health problems (even those with health insurance) cannot get the care they need;

* Managers for health insurance companies are making decisions about health care that should only be made by people who know and care about patients - their personal physicians, nurses, and family members;

* Doctors are given financial incentives to give less care, pitting health professionals against sick patients - the very people they are trained to help;

* Skilled nurses are disappearing from the bedside and multiplying by the telephone, haggling with insurance companies over patient care.

As with all good physicians who have made a diagnosis, Physicians for a National Health Program has a plan for a cure and full recovery. As the title of their group suggests, these doctors want the United States to adopt a single-payer, universal health system similar to the one we have in Canada. The group outlines the advantages of such a system:

* In all other industrialized countries, you can go to the doctor or clinic or hospital of your choice for care;

* All standard medical services are automatically covered;

* You never receive any hospital, doctor, or insurance bills;

* All family members are covered. You don't have to worry about your children, spouse, or parents losing insurance or having costly medical bills;

* Preventive care is covered for you and your family when you are well, and all necessary treatments are covered when you fall ill. Patients, not profits, are the primary concern.

And, here's the really good bit - a single-payer system would cost less. A U.S. Government Accounting Office study in 1991 found that national health insurance would save the U.S. more than 10% of all health costs annually. Simply cutting the paperwork caused by having hundreds of different insurers, $100 billion a year would be saved. This would be more than enough money to cover all the uninsured and provide better health care to the underinsured.

SUGGESTED ACTIVITIES:

1. In the summer of 1999, the New York Times wrote: "The struggle over health care, in retrospect, was one of the defining political conflicts of the 1990s." Appoint a team of students to research this struggle - President Bill Clinton's failed attempt to introduce universal coverage in 1994, the failed Republican overhaul of 1995, the failure of the Patients' Bill of Rights movement in 1998. Have the team analyze the reasons why attempts to reform health care in the U.S. meet with so little success.

2. Between 1979 and 1999, 44 people were awarded Nobel Prizes for medicine; of these, 28 (64%) were Americans or did their research in the United States. How can we explain this kind of progress in a country whose health-care system is so lacking in equality? Discuss.

Websites

The Commonwealth Fund - http://www.cmwf.org/

The New England Association of HMOs - http:// mahmo.vh.shore.net/ NEAHMO/neahmo2.html

Physicians for a National Health Program - http://web.pnhp.org/ pnhp/index.html

FACT FILE

The head of one Blue Cross HMO plan consumed an annual travel budget of $500,000 U.S., including one $7,000 U.S. trip to Africa to lecture on insurance fraud.

FACT FILE

The Danish health system costs only 6.7% of GDP compared to the U.S. 13.6% of GDP. At half the cost, the Danish cover everyone, and life expectancies for Danes and Americans are almost identical.

FACT FILE

In 1997, the infant mortality rate in Canada was six for every 1,000 live births; in the United States it was seven.

RELATED ARTICLE: PARADISE FOUND

Harvard University School of Public Health says Canadians have more confidence in their health system than Americans. In a 1998 survey, the school found that 24% of Canadians rated their health care as excellent, compared to 20% in the United States, and 15% in Britain. Only 10% of Canadians said they were unable to get needed medical care. This is about the same as in the U.S., Britain, Australia, and New Zealand.

According to Physicians for a National Health Program, "Private insurers take, on average, 13% of premium dollars for overhead and profit. Overhead/profits are even higher, about 30%, in big managed-care plans like U.S. Healthcare. In contrast, overhead consumes less than 2% of funds in the fee-for-service Medicare program, and less than 1% in Canada's program. Blue Cross in Massachusetts employs more people to administer coverage for about 2.5 million New Englanders than are employed in all of Canada to administer single-payer coverage for 30 million Canadians."

Physicians in the U.S. face massive bureaucratic costs. The average office-based American doctor employs 1.5 clerical and managerial staff, spends 44% of gross income on overhead, and devotes 134 hours of his/her own time annually to billing. Canadian physicians employ 0.7 clerical/administrative staff, spend 34% of their gross income for overhead, and trivial amounts of time on billing (there's a single half-page form for all patients, or a simple electronic system).

Dr. Gordon Schiff heads clinical research at Chicago's Cook County Hospital. He looks at comparative numbers such as these and dreams: "The Canadian system is so utopian and seems so far away and yet here it is right across the border. Canadians should be proud of what they have, understand why it's good, and work to defend it ... It's been there for more than 30 years and it works. It works to hold down costs, it works to cover everybody, and it works to offer choice."

RELATED ARTICLE: SINGING THE HMO BLUES

Most Americans used to have a health system that worked on a fee-for-service basis. People chose their favourite doctor, and doctors chose their favourite treatments; insurance companies paid the bills. The insurance companies recovered their costs plus a little extra in premiums charged to employers. But, costs started to spiral, and insurance premiums doubled between 1980 and 1993. The cost of health care was rising 13 times faster than the U.S. per capita Gross Domestic Product.

At this point, health-maintenance organizations (HMOs) entered the picture. An HMO contracts with health-care providers - doctors, hospitals etc. - to supply medical services to its group members. The idea is that a large group can negotiate lower fees for surgery, medication, and other treatments than individuals can. This care is usually paid for by an employer at a fixed price per patient. About 85% of Americans with health insurance are enrolled in HMO plans, often called managed care.

HMO supporters, including many physicians and patients, argue that managed care plans provide higher quality care than any individual physician can offer. As they see it, managed care plans are able to co-ordinate each patient's medical care, promote preventive medicine, and carefully monitor quality. But, not everyone is a supporter. In fact, the ranks of opponents are growing rapidly.

Critics say HMOs have created a bureaucratic system that reduces choice for all and forces doctors to place saving money before saving lives. To keep costs down a kind of rationing of health care has been going on. More and more stories are coming to light about the catastrophic results of patients being denied access to treatment by an HMO. One group of doctors operates a website that features an HMO "Atrocity of the Month." Such tragedies grab the headlines but they are usually isolated cases.

That said, there is a deep level of dissatisfaction with HMOs among both doctors and patients. In a 1995 study, 40% of physicians polled complained that managed care meant less control over medical decisions and less time with patients. One doctor complained that she was refused permission to give her patient an MRI test by a medical administrator who only had a high-school diploma.

Now, American businesses are starting to squeal. At first, HMOs held down the rising cost of health care. But by 1999, the cost of many insurance premiums was going up by as much as 9% a year. This may have a lot to do with the changes in the U.S. court system. In the early days of HMOs, the courts were reluctant to allow patients to sue for malpractice. This has changed, and people denied treatments by their HMOs are winning multimillion dollar settlements. The HMOs, not surprisingly, are moving to cover themselves by loosening their tight control over tests and treatments.