Single-Payer in North America

Former Iowa resident, and current Canadian resident Ann Bibby has posted a rant (via Abel Keogh) about Canada’s health care system:

Factoring access issues out (because family doctors – who are the gatekeepers to all other doors unless you opt to simply brave the emergency room), the main problem is timeliness coupled with time sucking runaround.

Back in Iowa, I could call my doctor’s office and generally get in to see her the same day. X-ray and lab were on site, so there was never a need to run about the city and diagnosis or action plan was meted out at the same appointment.

If I needed to see another doctor or have additional tests, it happened within a couple of weeks. Only rarely did one wait a month or more during the diagnostic phase. A good thing because though most issues are minor and not life-threatening, one can’t really know this for sure in the initial stages. Timely diagnosis is more than a little bit crucial. And so is treatment – depending.

Here it is a very different story. Nothing is on site at the doctor’s office. Nothing.

Accepting that her experiences in Iowa (same-day visit? Cool!) are not necessarily typical here (though hospitals are working on accepting acute care to keep people out of the ED), I found this significant. In part because Bibby is not a right-winger looking for things to dislike about the Canadian system. In part because it corresponds with what I have heard from others (even among people who like the system in the overall). Mostly, though, because it touches on my fear of what would happen if we tried to adopt Canada’s system.

I assume, to some degree, that Canadian’s love their system. They certainly talk about it enough and I vaguely recall seeing a poll that they are much more satisfied with theirs than we are with ours. Which is fantastic! They should absolutely hold on to the system that they love so much. The pertinent question, however, is not how much Canadians love their system, but whether or not Americans would. My fear, essentially, is that we would hate it and we would shift back to something more like our own system almost immediately.

If you have it, and if you can afford it, and if you don’t need to use it extensively, health insurance in the US isn’t a bad deal in the overall. Granted, those are big stipulations. Most Americans, however, are relatively taken care of with either their insurance plans, Medicare, or Medicaid. There was a reason that President Obama would (disingenuously) say, over and over again, you can keep your current plan if you like it because a non-trivial number of voters have insurance and like it. The catch, of course, is with those that don’t have it and/or cannot afford it. That is where our system – especially compared to Canada’s – fails.

I don’t mean to trivialize the frequency of our system’s failures with regard to the uninsured, but the fact that it’s not a majority of the voting public means quite a bit, electorally speaking. It means that whatever system we devise is going to have to be satisfactory to those who are covered. I am very concerned that the Canadian system will not be so satisfactory. I would further suggest that our hospitals and clinics already deviate so substantially from the Canadian model that we would have different results from Day 1. By Day 730, we’d already be seeing things down here that they aren’t seeing up there – things that would either undermine the cost advantages of the Canadian system or the advantages of universal insurance.

Another phrase for “a 9-week wait to see a specialist” is “cost-containment.” The problem gets better, people forget, things get lost in the shuffle. If that became an average wait-time in the US, we would go apoplectic rather than merely seeing it as a flaw in an otherwise great system. We likely wouldn’t have 9-week wait times, though. Nor would we have the separation-of-service that Bibby refers to. Our lack of separation of service is one of the reasons for our escalating costs (intra-practice referrals, profitable and overutilized testing equipment on site, and so on), and it’s a degree of savings that Canada enjoys that we likely would not.

So what would happen? One way or another, I fear the system would break down. Politicians of both political parties would be on board with ever-more aggressive patients-bills-of-rights. Or alternately, you might start seeing to see a parallel system develop. Government insurance would become like Medicaid. Medicaid is way better than nothing, but they are already put at the back of the line when it comes to getting care, and if enough people aren’t taking advantage of it, it becomes politically vulnerable. The Medicaid patient might have to wait, but the rest would throw more money at the system not to have to. This isn’t the worst possible outcome, by the way, and may still represent an improvement over what we have now. Maybe we’d find a way to deal with it in a satisfactory manner. But what would happen would not, in my view, look all that much like the Canadian system we seek to emulate.

We’ve grown accustomed to a different set of expectations, when we’re insured, and most voters are insured or have Medicare.

It may be selfish, but we’re going to have a hard time getting people to relinquish their expectations so that things can be better for people who are unlike them (and who they are disproportionately less likely to know personally). That, I believe, is the primary obstacle in front of us. On the one hand, we want some semblance of equality in our health care system. On the other hand, we want the best health care possible for us and ours. I don’t know of any system that is going to square this hole. If we can mentally surpass the obstacles (accept the downsides in the name of cost-containment and increased access for others), I’m not sure it matters what system we have.

Does this mean I oppose single-payer? No, actually, it doesn’t. It means that, after having come close to really liking the idea about six months ago, I’ve been moving away from it as a solution for us. At least, so long as I have no idea how it would work in practice and the more I have come to realize it wouldn’t work here the way it has worked elsewhere. I would, however, still very much like to see it tried here. Give Vermont their waiver. First Vermont, then Montana, then maybe Minnesota or some other state that wants to give it a try. If they can find a way that makes it work, then by all means we should adopt it nationally. I have, however, a lot of concerns I need mollified before I start coming back around to the idea again. I want to see what additional demands Americans make, and whether or not those demands can be satisfied.

Will Truman

Will Truman is the Editor-in-Chief of Ordinary Times. He is also on Twitter.


  1. In lefty discussions one issue that comes up is that our social service system has been worked and massaged and extended just enough to keep the screwed over/suffering to a tolerable extent. That doesn’t mean it works well but that the hurt is limited to a powerless and just small enough group that there is not enough push to fix it well. This seems to be what you are touching on. Our current health care system has widely recognised problems but is either good ( if you have money) or good enough that makes it easy enough for most people to worry about who is truly boned by the system.

    It sounds like Ann has been really lucky to not have been run around or denied care by insurance companies. Very lucky. Cost containment is always going to happen. I’d think we would be better off if we talked about it openly instead of hiding behind market discussions.

    I completly agree about american expectations. Americans want their fat free cake and to have taste as good as rich, sweet cake. We want all the good stuff we like in our health care , and have everybody be covered, it magicly cost less , and have no changes we don’t like.

  2. You know what else we have in America?

    Claims denied after service was rendered, because the procedure was covered but not within the first 6 months and the provider isn’t required to ensure that and a non-urgent procedure was done in month 5 and a bill sent month 7 and oh tough luck.

    Multiple providers required despite the fact that the primary providers is qualified to perform a procedure but oh the insurance only covers some of his services but not all so now two providers are involved unnecessarily.

    It seems to me that a (relatively) easy solution is to have a public offering that functions much like Canada’s that is complemented by a private system available to those willing/able to pay for it. Much like schools… anyone and everyone can attend a public school; folks who want more can go to private. Keep what you have. But no one gets left out in the cold.

  3. Hmmm… my comment seems to have gotten eaten. I’ll try again.

    I don’t think Ann’s experience is even generalizable across the United States. Where I used to live, the wait time for referral to a pediatric specialist was often several months.

    Further, as convenient as it may be to have a lab or radiology suite on-site, it raises questions about whether physicians are padding their bottom line by profiting from tests they order being performed in facilities they own. While it may cost in convenience to go off-site, it may have worthwhile benefits in keeping healthcare costs from rising inappropriately.

  4. Russell & Kazzy,

    It’s not a question of which system is better. It’s a question as to whether Americans will put up with the constraints of the Canadian system, many of which are required for cost-containment, or whether we will simply have the same problem with a different person/entity footing the bill. I consider Bibby’s testimony, even if it’s way off-base confirmation of my fears that we would not.

    So while it may be the case that it’s good for overall cost/benefit that Canada has a wall between its doctors and the tests they run, what are the odds that wall would exist – even temporarily – here? While we may consider the wait times there to be a reasonable cost so that the less fortunate among us get better care, what are the odds that we would actually put up with the wait times? Not good, I don’t think.

    Rather, I believe that the people who have it good now will demand that they continue to have it good. Either we will extend this goodness to everyone, and our costs will explode, or we will have a two-tiered system that will be radically different from Canada’s. It’s less a question of whether we should adopt a system like Canada’s, but whether or not we’re capable.

    It seems to me a lot of the “we should adopt single-payer” relies on “people will just have to accept…” in cases where I don’t think it would be accepted. Whether we should or not.

    • WillT-

      I suppose my point is that we don’t all have it that good. At least not as good as Bibby has it. I have it pretty damn good. And it is not all that good. Of course, everyone has different priorities. Some don’t give a crap about cost and care only about convenience. For others, the exact opposite is true. So it is really hard to say what “Americans” will or will not be happy with because we are not monolithic.

      To the broader point, you are right… change is hard. For people to lovingly embrace change, than whatever is “new” must not only be better than the status quo, but so much better as to make the transition worth it. We’re not starting from scratch and selecting an ideal system. We have an existing system that people have come to accept (and let’s not mistake acceptance with satisfaction or happiness) and moving them off that is no small feat. I just disagree with Bibby’s point that most Americans love their system because they can all get in to see the doctor the same day and all their doctors have every machine necessary in the building.

      • Yeah. This here is the rub:

        In late July, a Time magazine poll found that 55 percent of Americans rate their health care system as “only fair” or “poor.” Six-in-ten have a negative view of private health insurance companies’ job performance. But 86 percent of Americans still said, when asked, that they were satisfied with their own health care plan.

        One month earlier, an ABC News/Washington Post health care poll found that six-in-ten respondents backed reform and even the creation of a government-funded entity that would offer health insurance to the uninsured.

        But the same poll also found that about eight-in-ten Americans are, again, satisfied with the quality of their care and their insurance. Fifty-five percent of Americans even expressed satisfaction with the personal costs related to health care (including 61 percent of the insured). Kaiser Family Foundation polls in 2008 and 2006 echo the same pattern.

        I find it difficult, logistically, to square that with a request for sacrifice for the greater good (namely those that, as you point out, are being screwed by the system). I fear that Bibby’s response would be rather typical, and significant alterations would follow.

        • It almost makes it look like something that keeps the basic structure of our current system (like OCare) and offers assitance to poor people (like OCare) and expands the number of people in the current system (like OCare) is the best step forward.

        • It seems those numbers sort of agree with me… people accept the system and perhaps might prefer the devil they know to the devil they don’t, but they don’t necessarily love the system as Bibby insists.

          I think the real path to single-payer, if that is indeed the ideal path, will be lined with demonstrating to folks why it will benefit them, and that agreeing to such a reform is not something they are doing out of the goodness of their own hearts. Show them, long term, how the cost controls imbedded within the system will mean more cashmoney in their pockets. Do that and I think you’ll see those numbers shift.

    • Well, the bottom line is that Americans are going to have to put up with something they don’t like. There is no possible reform of our unsustainable system that will not involve some rather large group of people being forced to accept something they don’t like. To paraphrase a well-known movie, anyone who says otherwise is selling something.

      • Oh, I agree. But it’s the unwillingness to give something up that is the problem. Far more than the mechanism of payment.

        • There are really only two ways to ration a scarce resource. By Price or By Queue.

          If you want people busting their butts to make more of the scarce resource? Ah, you all have this speech of mine memorized already.

      • Russell,

        Did you see the graphs I posted in another thread showing that other professional services like legal and financial planning have increased at almost the exact same rate relative to general inflation as medical services? This isn’t anything funky; just straight-up CPI data from the Labor Dept.

        The only real unsustainable “crisis” we have here is that median wages have stagnated since 1970 or so while professionals such as yourself have simply managed to maintain your normal course of progress. And actually, physician services have inflated more slowly than health care in general–particular out-patient hospital services–so it’s not like you and your colleagues getting rich on the backs of the rest of us the problem either. (In case that’s what you thought I was implying.) I suspect a lot of the growth in the cost of physician services is actually the result of your increasing student loan debt and capital cost structure in your practices.

        The real problem here is that median wages haven’t kept up with either productivity growth or general inflation driven by resource and capital costs/profits. If they had, your average working dude would be making roughly double what they currently bring home. I suspect health care costs would look a lot more tenable under that scenario.

        Of course now I’m getting into 99% vs 1% nagging and “zero-sum” thinking and “outsourcing is really, really, good (or not)” territory. Basically a rehash of the inequality symposium and I guess we just have to suck it up for the greater good. Or at least so say the defenders of the overlord class.

        • Let me add that I’ve come to the conclusion that the debate about single-payer on the one hand and Free Market Now (TM) (Blessed Be His Holy Name) on the other is a big red herring. Professional services that exhibit none of the structural characteristics that are being blamed for the health care cost crisis–such as employer-provided insurance or government subsidies–are on the exact same cost curve. Legal services and financial services are running exactly parallel and veterinarian services are actually inflating somewhat faster than human health care.

          The striking realization is when you consider that the cumulative apparent excess inflation in health care would imply that our costs are at least double what they should otherwise be. So can someone please tell me where that 1.3 Trillion or so ANNUALLY is actually going? I don’t see anyone, not even the health insurers, that are sucking down that much excess profit. This isn’t a left or right thing; I’ve had to abandon blaming my favorite lefty whipping boy as well (albeit in favor of another lefty whipping boy).

  5. “There was a reason that President Obama would (disingenuously) say, over and over again, you can keep your current plan if you like it because a non-trivial number of voters have insurance and like it. ”

    I agree that such statements were disingenuous. Even though I supported the ACA pretty much from the beginning, I was disturbed by the declarations that the only thing we had to lose was unaffordable health care.

  6. There are a few things that I feel should be pointed out:

    1. Yes, wait times seem to be longer in Canada. That’s *the* biggest problem with Canadian health care (not finding a family doctor being ever-so-slightly behind, I’d argue). It’s generally considered the trade-off. We get longer wait times, but everyone has coverage. So, it you don’t like that trade-off, you’re going to be annoyed.

    That being said, it is something that we are regularly working on (the feds just scolded the provinces about this, I believe). I think it’s improving, and I think it’s a better problem to have. As well, the Supreme Court has already confirmed that people have a “right” (for lack of a better word) to reasonably quick treatment (it was an Ontario case – the patient went to the U.S. then demanded that OHIP – the Ontario health insurance program – pay for it; OHIP declined, the judges forced them). This isn’t ideal for everyone, but with considering the number of citizens living relatively close to the U.S. or to other provinces, it should exert some more pressure on fixing things.

    2. The lack of family doctors is a real problem. It adds to wait times and drives up costs. However, a lot of jurisdictions are working on alleviating it, as well as creating more critical care drop-in centres (sort of like a beefed-up clinic). It’s not great, but it might help.

    One big problem, as I see it, is that in Canada the government artificially limits the number of med students. This means that there is no way for us not to have a shortage of doctors. Assuming that the U.S. doesn’t adopt that (and considering the number of private universities – which we lack – I can’t see that happening), there shouldn’t be as much of a problem (the same would go for specialists, ER docs, etc., I would assume).

    3. Location really matters here. She’s from Alberta, but I didn’t see where in Alberta. I’m going to guess that access to health care is better in Calgary than it is Grand Praire, which is probable better than it is in Bon Accord. But, I don’t know the Alberta health system very well.

    The idea that we need more full-service health facilities seems bang-on to me. In Ontario, there is a push to create more of these. Anecdotally, it seems that every new medical office building either has labs/ultrasound/pharmacy/etc. in the building, or a door or two down. Of course, I live in a growing urban area, so that might be the reason (though I still think it indicates the trend).

    4. Finally, I think the tone of the post demonstrates what is so very wrong with so many health care debates. In Canada, we often here of the evils of “Americanization” if we happen to suggest moving any aspect to the private sector, or if we even just try to figure out what ways the American system works better. It is deemed unpatriotic to suggest that our system is flawed to such an extent that we could learn anything from the private U.S. system. It is, too often, a binary discussion – either you’re for universal health care coverage or you’re for a private system. I think this is the biggest impediment (at least in Canada) to improving our health care system.

    • I can’t tell you how much I appreciate this response, Jonathan. I want to respond more later, but I want to mull it over and I’ll be in the car four hours today. But I wanted to make sure to say that I really appreciate this.

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