Friday, March 20, 2009

Health care as human right, not market commodity--an American physician speaks out

Dr. Marcia Angell has a message for Canadians: Don't be too quick to judge the U. S. system as superior to what is already in place in Canada.

I can already hear the "boo birds" bashing this post.

But, that's okay. We've been working for almost 20 years in the world of hands on medical service delivery and I've got to tell you the gaps and the people falling through them call for some fresh new thinking about how we do health and wellness here in the U. S.

Read her article in the Canadian Medical Association Journal.

The key points of the essay include:

• Health care costs per person are twice as high in the United States as in Canada.

• The US health care system has worse outcomes, is less efficient and provides fewer of many basic services than the Canadian system.

• The United States is the only industrialized country that treats health care as a market commodity, not a social service,and leaves uninsured those who cannot pay.

• In the United States, for-profit health care is more expensive and often of lower quality than not-for-profit or government care, with much higher overhead costs.

• The notion that partial privatization in Canada will shorten waiting times for elective procedures is misguided.

• Partial privatization would draw off resources from the public system, increase costs overall and introduce the inequities of the US system.

• The best way to improve the Canadian health care system is to put more resources into it.

Angell is clear: privatizing health care in Canada is not the answer.

In our arrogance, we seldom take a hard look at the facts of the system employed by our good friends to the north. Hear her out.

Almost 50 million of our fellow citizens would likely find her point of view very interesting indeed.



Anonymous said...


I don't know how you find all the valuable info that you find! I just skimmed most of the article from which this was taken. It reminded me of this post by a reader on Andrew Sullivan's blog:

The Coming Healthcare Battle, Ctd.
A reader writes:
As a Canadian living in the States, it's been interesting to watch as more and more Americans become aware of their deteriorating healthcare system. For me, it's meant an ever-increasing trickle of people (of broader and broader political perspectives, I might add) who come to me to talk about Canada's system. I begin every conversation the same way: Both systems have their flaws. You'll find unhappy people in both systems. The truest non-empirical test I have is to point out that I have known many people who have lived in both systems (i.e., Canadian and American), and I still have never met a single person who preferred the American one.

Randy Mayeux

Larry James said...

Randy, thanks for the post, very useful to this discussion. We have a very hard time moving beyond predictable rhetoric in this country on this subject, don't we? I think Mr. Sullivan's reader is correct though, times are changing. BTW--the tip on this article came to me from one of the members of my Board of Directors here at CDM.

Daniel Gray said...

PBS Frontline had a really good episode about a year ago, I think it was called "Sick Around the World." It did a really good job of laying out different methods of universal healthcare currently in place and weighing the positives and negatives of each system.

Chris said...

Dr. Angell is an American physician, not Canadian.

I'm sure you think food, clothing and shelter are also human rights so why don't we just go completely communist and be done with the arguments?

Larry James said...

No where in my post do I say that she is Canadian. The link to her bio makes that clear. And, yes, I believe food, clothing and shelter are indeed human rights, as in "life, liberty and the pursuit of happiness" clearly historic, naitonal values, right?

Daniel Gray said...


I fail to see why doing those things makes us communist. We're not trying to make everyone equal financially, we're just trying to ensure that everyone has access to aspects of basic survival.

Our own constitution says that we are to support the general welfare. You might think that all of us are islands and that we do not depend on each other. But when people are sick and cannot work, or they starve to death, or don't have a basic education or housing, it harms the general welfare of our society. It drains our society even more by NOT addressing these problems.

We provide these things, because without them, people do not have the basic necessities that allow them to achieve their highest potential. And without a society of people who are able to achieve, we become morally bankrupt and we will fail.

All people should be able to be healthy. Good health is a basic necessity of human functioning and survival.

I work with people who are chronically homeless, most of them because of mental health problems. When we provide them with healthcare and housing, we are often amazed at their potential and resiliency. When we provide basic supports for human survival and functioning, we will see the contributions of these people in promoting a healthy society. It's not communist -- it's at the heart of being American -- recognizing each individual's liberty and independence.

Chris said...

A minor point but you did say...A Canadian physician speaks out."

If medical care, food, shelter and clothing are human rights, what incentive would anyone have to get out of bed and go to work?

The pilgrims experimented with socialism and it didn't work. William Bradford found that the most creative and industrious people had no incentive to work any harder than anyone else unless they could utilize the power of personal motivation.

Anonymous said...

Perhaps, Chris, you are ignorant. Perhaps, instead, you are a jerk and a troll. I cannot tell.

In both your posts, you argue against government-provided healthcare using bifurcation and a straw man: specifically, in each case, you label the proposal with a "bad name" that you intend to associate with instances of ostensibly failed policy (state communism and Pilgrim "socialism") without demonstrating that the proposed policy is correctly labeled. You further make a slippery-slope argument about work motivation, which is simply a very short-circuited form of question begging.

Adults who know how to think and argue are not convinced by such fallacies. This is why we find your posts annoying and suspect you either of ignorance (of both the policy facts and the methods of correct argument) or of knavery.

Please correct this.

And please don't respond with an ad hominem criticism of the provider of the linked content.

Jeff W

Eric Livingston said...

Our current health care system is just one more example of how Americans assign value to people based on their ability to generate wealth.

Christians ought to be assigning value to people based on the facts that they are made in the image of God, that everyone shares an equal plight of depravity, and that Jesus came to save all people.

belinda said...

Almost every other country in the world has some sort of socialism. I think we're told how "bad" it is so we'll feel superior in some way. I love the U.S., but we still have some serious problems that need to be addressed. NO ONE should be denied health care due to inability to pay for it.

Larry James said...

Chris, now I see! Thanks for the correction. I had made it before posting in the text, but forgot the title. . .duh! Your bringing the error to my attention is much appreciated.

rcorum said...

I just wonder if her comments are in any way representative of the views of the average practicing American physician. In 2005 I had quadruple bypass surgery. I am glad it was done in America, and was done without waiting in line.

Larry James said...

I think they are, rc. A medical pro sent the article to me. And, the myth that serious and non-elective surgeries must wait in Canada is simply not the case when weighed against the evidence.

Here's something almost no one ever mentions: how many poor, uninsured Americans must wait for treatment and surgery that is non-elective? I see it every day. We must do better as a people. Then, there is the matter of ROI--we are not getting it done in the world of public health for all that spend.

Lorlee said...

I recommend a book "Worried Sick" A Prescription for Health in an Overtreated America by Martin Hadler

Explains why we pay so much for such poor outcomesand how little evidence there is for many things we do -- even bypass surgery. Very eye-opening.

And from that book: "William McGuire, when forced out as the CEO of United Health Care, was realizing annual bonuses greater than $100 Million and had accumulated stock options in the billions."

Now tell me that doesn't appall you. Think how much health care that would buy.

Anonymous said...

I hesitate to throw this in because it is anecdotal, but here goes. I have a Canadian friend who loves her country and is generally very supportive of the way things are done there. But mention the Canadian health care system and as often as not she rolls her eyes. While it is great at handling routine matters, she can tell you several stories about friends who were told they would have to wait months for a needed procedure and came to the US instead. If she were a knee-jerk conservative I would wonder, but she is very reasonable and centrist. Her stories just confirm what we hear about the limitations of Canada's medical system.

Chris said...

Often whether surgery is elective or not depends on preliminary tests. An MRI here is essentially same day service. In Canada it is about 10 weeks. Check out: "A Short Course in Brain Surgery." (a Utube film)

rcorum said...

I think that part of the problem is that the issue of healthcare is so politically charged that it cannot be dealt with in a truly bipartisan manner. At this point i have no trust in the Democrats and very little with the Republicans. There is no doubt that our healthcare delivery system needs reform, but I find it incredible that anyone thinks the government can do a better job.

Anonymous said...


I think if most folks are like me, their concern is more in the delivery of the system and not the idea of universal healthcare itself. No one wants a bureaucrat determining whether or not you receive a certain service or whether you are too costly to the system. The devil is in the details and that plays on our insecurities.

Paul Smith

Larry James said...

Paul, good to hear from you! I understand your concern. However, I think that the fear is misplaced. The current bureaucracy of private health insurance in its various forms creates some of the very problems you fear. Then, there is the record and experience of Medicare--a public health insurance program. I've just been through the final years of my parents' lives. I can't tell you how great Medicare was for them. The actual administrative costs for the Medicare system is meagre indeed when compared to the cost of private insurance programs. We'd save over $45 billion annually as a nation, as individual citizens if we moved away from the current, private, for-profit system. Thanks for the post.

Anonymous said...

Just love how you accept the American Doctor's arguments whole, not a critical thought in your head.

Need to see a specialist fast? Too bad you're not a dog.
Rover will see an oncologist within days; you'll wait five weeks for a consultation. Bum hip? You could wait over a year. Cataracts? Three months. Whiskers could get both fixed tomorrow.

Also at
No horsing around
Inside one of Canada’s most sophisticated operating rooms—for horses
Dr. Danny Joffe is only half joking when he says that if he'd fallen asleep on the last day of vet school in Saskatoon and woken up some two decades later in his current workplace, he would not have believed it was an animal hospital. Joffe is one of 11 specialists at the C.A.R.E. Centre, a 28,000-sq.-foot palace of veterinary medicine built two years ago in Calgary by a consortium that owns 23 vet clinics and animal hospitals across British Columbia and Alberta. It has four operating theatres, a $100,000 CT machine, two ultrasound machines, a digital X-ray unit, an endoscopy centre, a lab and 16 examination rooms. Its intensive care unit boasts 20 cages and eight dog runs, staffed 24/7. "It's just like an emergency centre at a tertiary care human hospital," Joffe says.
There is almost no pet illness that can't be treated here. For eye problems, C.A.R.E. provides ophthalmologists who perform cataract surgery. Orthopaedic surgeons do hip replacements or arthroscopy — minimally invasive surgery on joints. To treat cancer, a surprisingly common disease in dogs and cats, says Joffe, "Our oncologist can offer intricate chemotherapy protocols and our surgeons can do very extreme and elaborate surgeries, including mass removals, amputations and bone transplants from cadaver dogs." As for MRIs, C.A.R.E. has a standing two appointments a week booked at a private human facility in the city. "For you or I it might be a several-month process," says Joffe of getting an MRI. "We get it done in a week or less."
And how. There are just 10,800 vets in this country compared to over 62,000 human doctors. But try, as a human, to get an appointment with a specialist. Try, for that matter, getting a GP — five million Canadians, about 15 per cent of the population, don't have one, while 15 per cent of those who do still report trouble receiving routine care. And a referral from your family doctor to a specialist puts you in store for a new ordeal. According to the most recent edition of "Waiting Your Turn: Hospital Waiting Lists in Canada," the Fraser Institute's annual survey of wait times across the country, the number of weeks people waited to see a specialist rose from a median of 8.8 in 2006 to a median of 9.2 weeks in 2007. The journey from specialist to actual treatment took a median of nine weeks after that.
Or try getting a CT scan. The median wait in Canada in 2007 was 4.8 weeks, a little less than that in Ontario, Alberta and elsewhere, but a median of eight weeks if you were in Manitoba, the lengthiest delay in the country. An MRI scan? The median was just over 10 weeks, though in Newfoundland and Labrador you waited a median of 20. Got a bad hip? Try and find a comfortable position on the couch, you'll wait a while — ranging from a median of 15.5 to 80 weeks from the time you see a specialist to the time you get a new hip, depending on where you are (half of Canadians received treatment within the provincial wait times benchmark of 26 weeks or less, still an awfully long slog, and still longer than doctors would like to see their patients wait, whatever the benchmark).
You waited a median of 13 weeks in Alberta for cataract surgery in 2007 (the median now sits at seven weeks, though most wait 23 weeks, according to provincial numbers), 12 in B.C. (current provincial numbers shave that down to a median of eight), but as long as 24 weeks in some parts of Canada. Meanwhile, your friend Fluffy likely got cataract surgery in just a few days — provided you paid for the privilege.
Between the time a woman books a date with an oncologist in Alberta for breast cancer and the time she is finally seen, she'll wait a median of two or three weeks, according to Alberta Waitlist Registry data for the 90 days preceding Feb. 29 this year. She'll wait a median of a week between then and when she actually begins chemotherapy, too. If you're looking for a radiation oncologist, pencil in a date between two and 10 weeks from now just to have an appointment, then prepare to wait a median of as much as six weeks to start radiation therapy. Those prospects would make Ginger howl with despair; duller canines might just grin and bear it.
As for cost-per-procedure — though in most provinces you're not allowed to pay — finding out how much the province shelled out for your hip replacement or cataract surgery puts us on treacherous ground. "Nobody knows what the cost is," says Rick Baker, founder of Vancouver-based Timely Medical Alternatives Inc., which seeks the best prices for private medical procedures across North America for Canadian clients. (He operates a similar business for Americans.) "Why do they not know? Because they don't need to know," says Baker. Hospitals in Canada are funded on an annual basis, not according to the number of patients they see and what ailments they treat, as in the realm of animal hospitals. "All they know is they get $50 million per hospital from the government. If you ask about a specific procedure, they wouldn't have a clue."
The cost of not knowing what procedures at Canadian hospitals are worth is systemic sloth. "Under global budgets, you really don't find complete cost accounting because there really isn't an incentive to do it," says the Fraser Institute's Nadeem Esmail, co-author of "Waiting Your Turn." "It really does affect efficiency because you can't tell precisely where the inefficiencies are." Adds Canadian Medical Association president Dr. Brian Day: "We have excessive costs of administration and we have excessive costs of wait lists." Wait lists create new expenses because deferred treatment produces a greater risk of complications, says Day. And sick folks who can't work because the health system makes them wait also sap the economy, he says. When Canadians do make it to hospital, they end up languishing in aging buildings operated under lumbering bureaucracies and suffering paralyzing staff shortages.

McLean's is a Canadian magazine. But you won't finish the article. You've already made up your mind.

Anonymous said...

Anon 1:18, your post is even more one-sided than the doctor Larry quoted. I'm wondering as I read it all (and knowing larry, I'm sure he will as well!), what is the motive behind this essay? How does one explain Canada's overall better grades for public health across the population? How about the per capita cost? Or the % of GDP annually spent on medical care?

May I ask a question? What do you do for a living?

Anonymous said...

Just a statement of statistics related to the Canadian healthcare system for people and their pets.

motive behind this essay?

You'll have to ask the authors.

How does one explain Canada's overall better grades for public health across the population?

You'll need to cite a source for this claim. I don't know whether Canada gets better grades, or whose grades you may be referring to. I am sure the patient waiting for the oncology visit doesn't grade on a curve.

How about the per capita cost? Or the % of GDP annually spent on medical care?

Would you trade cost for quality? Cost for speed? Cost for innovation? The authors seem to dispute the notion you can determine cost of procedures, b/c there is no figure for specific figures. So per capita costs is the only figure to go with. So how do you account for those not formally entering the Canadian system? Is per capita cost a good number? If 15 percent of Canadians don't have a GP how do they get treatment? 21% of Americans do not have insurance coverage, but have medical care whenever they show up at a hospital. 15 percent of Canadians don't have medical care. Which is better?

What if I were a United Auto Worker? A Civil Servant? An administrator at an engineering firm? A teacher? A cost analyst? Would it matter? Why?

Mike Katz said...

Indeed Canada is way ahead of the USA on many quality of life issues.

Having dealt through business with many Canadians over the years I never had a bad critique of their healthcare system. We spend three times more than some of the best systems around the world and do not have the best treatment or outcomes.

The fact that with all of our economic strength (at least in the past) we have 45 to 50 million Americans without insurance which means unless you have cash you do not get care easily and when you do it is in ER setting that is so costly and maybe too late. And then there are the additional 35 to 40 million of us that are underinsured due to unaffordable cost of the insurance or barriers created by the insurance underwriters.

Something is wrong when the biggest reason for personal bankruptcy is because of medical bills.

Mike Katz

Anonymous said...

True enough, Mike. But the study noted below indicates that most of the health related bankruptcies were filed by people WITH insurance.

So clearly it is not the absense of insurance that caused the bankruptcies in the majority of cases.

I've often marveled how the discussion of medical care has turned to focus upon insurance, not the availability or quality of the care, itself. Yes, in an ideal world we would all pay a moderate fee for insurance. But not all people have the funds, not all would buy the insurance if they had the funds, and not all those with both the funds and the insurance will seek medical care, when needed.

Universal insurance coverage has been substituted for universal health coverage. The whole concept of providing universal health care would be a lot easier to swallow if programs like SCHIP ( were not manipulated to include 33 year old adults.

Try universal care and see what happens:

Medical Bills Leading Cause of Bankruptcy, Harvard Study Finds

February 3, 2005
Illness and medical bills caused half of the 1,458,000 personal bankruptcies in 2001, according to a study published by the journal Health Affairs.

The study estimates that medical bankruptcies affect about 2 million Americans annually -- counting debtors and their dependents, including about 700,000 children.

Surprisingly, most of those bankrupted by illness had health insurance. More than three-quarters were insured at the start of the bankrupting illness. However, 38 percent had lost coverage at least temporarily by the time they filed for bankruptcy.

Anonymous said...

I suspect a great deal of the difference between Canadian outcomes and American outcomes relates to relatively simple preventive measures that their system can deliver well and that make a big difference, from vaccines to keeping asthma and high blood pressure under control. The US system appears to be more attuned to high cost, complicated solutions once a problem has appeared. Hence Canada's good overall numbers, but complaints about waiting if you need a specialist. Hence enormous US costs but lesser overall outcomes.

Anonymous said...

There are many behavioral differences between Canadian and US populations that impact the ability of the health system to respond effectively. Food options/choice, exercise, family structure, crime rates, hours at work, commute time, etc. Generally, we in the USA are overweight, overstressed, more subject to random criminal activity, work longer hours, spend more time in a car, spend less time in leisure activity.

Can these things be controlled? Legislated?

Anonymous said...

Anon 9:46, just wondered if you might be conflicted by your professional self-interest in this discussion. So, I ask again, what do you do for a living?

Anonymous said...

"What if I were a United Auto Worker? A Civil Servant? An administrator at an engineering firm? A teacher? A cost analyst?"

D'oh! You've outed me. I'm a undercover republican political hack who has been assigned to blog patrol by the folks back at Central Control.

Actually, I've been all the above (except for the undercover republican political hack) and currently I am professor at a small private university. I teach business ethics, among other things.

So do you think I am conflicted? Is there any hope for me? What is your prognosis?

rcorum said...

Mr. Professor. Please continue to post. I think you offer a well reasoned response to a good deal of Larry's well intentioned left wing posts. I say this with great respect and affection for Larry.

Anonymous said...

Freedom of the individual isn't mentioned here. I want to be free to pay for the medical care I choose, and not pay for anyone else's. It is my right to have my own self interest come first.
If others are concerned about someone else's healthcare, they are free to donate voluntarily from their own bank account and not involve me.
Much of the reason US healthcare is expensive is because we don't have a true free market system. Insurance and government programs decouple spending from the person paying the bill. There is little incentive from the end user to control costs or limit demand.