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.