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Friday, March 14, 2014

Healthcare: The U.S. versus the Rest of the World

A great video.  This is a U.S. Senate hearing about healthcare in the United States and Canada. The two senators asking questions are:  Bernie Sanders of Vermont (Independent) and Richard Burr from North Carolina (Republican).  The ladies being questioned are:  Dr. Danielle Martin of Toronto, Canada and Sally Pipes of the Pacific Research Institute in San Francisco, U.S.

The background to this debate is important.  The Affordable Care Act was passed in 2010 and I was amazed that it ever saw the light of day.  For years there has been sharp debate about reforming the American healthcare system.  That debate turned downright hostile and ugly right up until President Obama signed it into law.  Ever since, there have been efforts to repeal it and it didn't help matters that the rollout went very badly.  There is something in the ACA legislation for everyone to hate.  What I heard when I was in Seattle last summer is that the Left in the U.S. says it doesn't go far enough and is basically designed to make private insurance companies rich and the Right says it's just another big intrusive government program that will bankrupt the country sooner or later.

As for the American diaspora there was real concern last year that the mandate to have healthcare would apply to them which is silly because many already have access to healthcare programs or very reasonably priced healthcare in the countries they live in.  The idea of paying twice made some of us rather testy but the good news is here.   Or is it good news?  The rule is that US citizens abroad can avoid the ACA healthcare mandate provided that they stay out of the US for at least 330 day in a year.   So, if you are an American abroad, long stays in the U.S. are out. Another incentive not to come "home" for a visit?

What struck me the most about the debate was the insistence on the part of the Republican senator on the awfullness of non-U.S. healthcare.  Now I'm a pretty conservative lady but I spent over 20 years of my life under the U.S. healthcare system and then 20 or so under Japanese and French healthcare.  Hands down, the healthcare was better, more accessible and affordable outside the United States.  And it's not just my subjective experience that says so, it's any number of organizations that don't have any reason, frankly, to say good or bad things about U.S. healthcare like the World Health Organization. (For those who say that the WHO does have a reason because "everybody hates us" - Oh, get over yourselves.)

The fact (and it is one) that U.S. healthcare is not the "best in the world" does not mean that the Affordable Care Act is the only answer.  What one Seattle Democrat said to me was:  "Well, it was the best we could do."  Wow, what an endorsement.

So I'm going to reserve judgment and see what happens.  But when I see American lawmakers dissing other systems and trying to shore up an untenable position, well, I have something to say about that.  The argument should not be about who has the "best" (though as a cancer patient I'm happy to be living in what most argue is the best healthcare system in the world), it's about coming up with the best system for the United States - one that gives good care to every homeland citizen at a price that is reasonable and sustainable.  I may swing conservative in many ways but I am adamantly against any human being suffering and dying because they can't afford care.  That's just not right.

And just for fun, a Flophouse reader pointed out this study by the AARP, Association of American Retired Persons (not a radical Socialist organization as far as I know)  called 5 Myths about Canadian Healthcare.  It certainly answers one of the most common assumptions of some Americans which is Canadians are just flocking to the US to escape their dreadful system.  AARP says, no, over 99% of Canadians don't head south for healthcare....


Anonymous said...

Unfortunately, the better off US citizen living abroad will still pay the 3.8% charge on net investment income despite being unable to take advantage of Medicare which the charge is designed to fund….

Anonymous said...

It's quite unfortunate that a requirement to purchase private insurance under threat of personal sanctions is called a health plan. Simply calling it a "health plan" has created widespread joy for those who believe in public healthcare. But it is a requirement to purchase insurance.

Unfortunately also, is that this law demands not insurance, but a pre-pay system. I used to have "insurance", which I paid for protection against any hospital bills over $10,000. I had always (rightly) assumed that I could pay for normal services but did not want to risk paying bills stretching over such an amount.

The current ACA system requires one to pay in to the insurance, and to receive payments, with little respect for deductibles. So, one is paying for management of ones billing services.

This requirement makes it really impossible for a student to come to USA for a short time and purchase such catastrophic coverage. The student must instead pay for that full billpaying management system.

On another tact, the best healthcare system I saw was in Thailand. It was tuned correctly to the country. The hospital workforce performed functions in the way that is most appropriate for the working culture there. One could go in and come out in 2 hrs, without appointment, and go through the entire diagnosis and consultation and prescription functions. The cost to the patients was well tuned to the local population.

In contrast, Sweden's has improved in the last years, coming out of the ice age of socialistic mediocrity and 18 month waiting lines. Now, it is quite ok, although it has quite a few weirdnesses that pop up often.

The fact about it all is that healthcare is a very very expensive service and no matter what means are used it costs a boatload of money.

Patricia said...

AARP had a comparison of US and Canadian Health care systems titled 5 myths about Canadian health care, almost all US health care for the Canadians resulted from incidents that occurred in the US. AARP also discusses the best medical tourism destinations; US residents are the greatest numbers seeking medical outside their country.

Peter W. Dunn said...

I am not terribly impressed with sickcare in Canada or anywhere for that matter. The 40-lbs gorilla in the room is the one few see: doctors are good at killing but not very good at restoring health. The body is still mostly a black box and they are experimenting with patients. Why would we want to give such people monopolistic power over health through state-run system, when other health professionals are fast gaining significant credibility, including those whom doctors have traditionally called quacks: naturopaths and chiropractors.

Example: I read several books on heart disease, cholesterol and statins. My conclusion is that doctors as a profession (there are exceptions) have no idea about the function of cholesterol, the difference between a lipoprotein and cholesterol, think that high "cholesterol" is dangerous, and that statins are necessary to lower cholesterol levels in about half the population. That doctors get most of their information from pharmaceutical companies is troubling. We need to break the monopoly of these people and put them on equal footing with snake oil salesmen on the internet. State-run health care? Isn't that just simply about placing one guild above all others and eliminating the competition?

Unknown said...

"Unfortunately, the better off US citizen living abroad will still pay the 3.8% charge on net investment income despite being unable to take advantage of Medicare which the charge is designed to fund…."

Virtually all US retirees receiving Social Security have opted for Part B of Medicare (a one time option). The cost is 10% of the benefit and is deducted from the SS payment. However, Medicare is not payable out side of the US.......

Tim said...


There are a couple of issues. Canada has two VERY good academic medical centers at McGill and University of Toronto that are very much equals of their US counterparts. Having said that their are huge differences between Canadian provinces and in particular Western Canada has much more of a UK NHS type system that I have less positive to say about.

The legal requirement to purchase "private" health insurance does exist in several non US countries including Switzerland, the Netherlands, and Singapore. These were the countries that Massachusetts modelled its system after and in turn the US Federal Govt under ACA modelled its system after Massachusetts. Note: the insurance mandate pre Obamacare was something at a global level only in smaller high context jurisdictions.
I will also add that at least in Massachusetts "private" health insurance is provided predominantly by "not for profit" companies like Tufts, Harvard Pilgrim et all. This is actually significant as many of the for profit HMO's like Aetna and Cigna are headquartered just to the south in Connecticut.
The other thing I will add is there are huge differences in level of health care delivery especially among different parts of the US. Take the provision of Level 1 Trauma care. Boston has five Level 1 Trauma Centers(MGH, Brigham's, Tufts, Beth Israel, and BU/Boston Medical) and two pediatric Level 1 Trauma Centers(Children's and Tufts Floating). Within a two hundred mile radius there are also level 1 trauma centers at Worcester(UMASS Medical), Providence(Brown), Springfield(Tufts Baystate), Hartford, New Haven(Yale), and Dartmouth Hitchcock in New Hampshire.
San Francisco on the otherhand has ONE and only ONE Level 1 Trauma center with neighboring centers in San Jose and at Stanford University. Your home state of Washington refuses to even participate in American College of Surgeons hospital accredidation process so we don't even know how the hospitals in Seattle would be classified. In Toronto they have two Level 1 centers(Sunnybrook and I forget the other downtown).

Tim said...

* In care you are curious France uses a much different system of classifying trauma care but basically in Paris there are four level one trauma centers compared to the five in Boston(a much smaller city than Paris). In France though there is a very bureaucratic process to get permission become a trauma center. In Massachusetts all you have to pass the ACS accreditation. The state does not put limits on the number of hospitals who wish to provide trauma care.(You do need to participate in the Boston Medflight helicopter service)

Blaze said...

"Red blooded high testosterone capitalists" in Canada see Canada's single payer public health care system as "perfectly consistent with capitalism.

On the other side of the argument, Jesus might not see the American system as compatible with Christianity.

What would Jesus do? Move to Canada.

P. Moore said...

Maybe those Senators should be comparing the U.S. health care system to Cuba's where life expectancy is closer to that of the United States (Cuba 79.3 yrs, USA 78.9 yrs - Source WolframAlpha). The US ranks 51st, Cuba 48th, while Canada ranks 16th.

Just a thought.

Victoria FERAUGE said...

@anonymous, That's a very interesting take on it. So you have to buy a full plan?

@Patricia, Thanks for the heads-up. I added it to the post. It was great.

@Peter, I am thrilled with French healthcare. Is it perfect? No, but I'm alive today because of it. I got in so fast when they started finding tumors. And none of my doctors here has to consult a list or ask if something is covered. On the other hand they are pretty conservative - they try not to over-treat people and they are very open to some kinds of homeopathic medicine. I'm still breathing so far, so I'm happy.

@Tim, Good point that there are regional differences. Why does Boston have so many trauma centers? Is Boston a dangerous place?

@Blaze, Great links and I love the one you sent me via Twitter. I just replied. :-)

@Patrick, Oh yes, some of the US stats really suck. Some of it is healthcare access, I assume, but life expectacy is not all about access to healthcare. And, of course, we all should remeber that we are all going to die of someone at some point. I still have my chemo shunt to remind me of that when I get dressed in the morning.

Northerndar said...

My son and husband were both treated at Sunnybrook Cancer Centre in Toronto. They received excellent care. The family also as a whole too. With individual and family counseling, and nutrition. It was 3 years of being there and seeing the good they do. I moved up to Northern Ontario where MRIs are not in every hospital. My small town of 1300 has no MRI so when I had to have one I was sent 200 km north to Timmins. There was no wait. Plus the Ontario Health Insurance Provincal (OHIP) paid for my gas in a travel grant. I don't mind paying through my taxes for my health care. I have supplemental to which covers dental, eyeglasses, massage and hearing aid , etc.
Thanks Victoria for putting this in your blog. I saw Sicko the movie and saw how more advanced France is in their health care.

Northerndar said...
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Northerndar said...
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Tim said...

Why does Boston have so many trauma centers? Is Boston a dangerous place?" I am going to have to ask my friend who works for MGH. I suspect she will have a pretty good laugh. In one word NO.
Trauma care is something is very few people ever need but for those who do need it is probably the difference between life and death. It is also by far the most EXPENSIVE type of medical care and most jurisdictions/countries even ones with really good health system don't want to spend the mega bucks required to provide such care. A seriously injured partient requiring Level 1 care can cost a million dollars in just a couple of days. I would say only a few areas like burns and high risk pregnancies are even more expensive. Burns are really a subset of trauma and Boston has two burn centers while Seattle and San Francisco only have one. I don't know as much about high risk pregnancies other than in Boston they all go to Brigham and Women's(also a trauma and burn center).
To my earlier point the number of centers in Boston has nothing really to do with need. Boston has a high number of Medical Schools(Four) and one of the highest concentration of pharmaceutical companies in the world(Including the main research center of Sanofi the largest French pharma company). It was basically the birthplace of modern American medicine(imported from France in the 1840s). Mass General(MGH) and Brigham's which are under common management received more NIH funding than any other entity in the United States other than the entire University of California system.
Here is an article below that tries to describe some of this:

Tim said...

In the aftermath of the Boston Marathon bombing on April 15, Level I trauma centers at six area teaching hospitals treated hundreds of patients, many with serious injuries. The coordinated response was successful: Everyone who made it to the hospital that day survived.

Before the Boston bombing, the AAMC had scheduled a May Capitol Hill briefing to emphasize the role academic medicine plays in trauma care. Speakers at the briefing noted that the large number of Level I trauma centers in Boston was one of the key reasons for the successful response. At the same time, they expressed concerns about the impact of federal budget cuts on trauma centers, including potential closures and reduced access to trauma services.

According to experts at the briefing, if a similar disaster were to strike in a locale without immediate access to Level I trauma care, more casualties would be likely because most areas are not as well equipped as Boston.

Mary Devine, emergency management coordinator with the Conference of Boston Teaching Hospitals, who spoke at the briefing, described the response that day in Boston.“Within minutes, the trauma centers cleared out their emergency departments, opened up the operating rooms, and said, ‘We are ready. Send us whoever you have.’”

Some states have only one or two Level I trauma centers, according to the American Trauma Society. Of the 4,985 hospitals in the United States, only 112 are verified by the American College of Surgeons (ACS) as adult Level I trauma centers. More than 80 percent of these trauma centers are operated by AAMC-member teaching hospitals.

Experts at the briefing noted that high costs have forced some existing Level I trauma centers to close. A 2009 Medical Care study showed that 339 trauma centers, including Level I centers, shut their doors between 1990 and 2005 because of inadequate funding. Trauma centers nationwide also are at risk from sequestration’s 2 percent cut to Medicare reimbursements, which could force more closures because Medicare is the main funding source for trauma centers.

“Boston-area hospitals’ coordinated response to the marathon bombings and the ongoing research and education initiatives at all Level I centers demonstrate the important role academic medicine plays in trauma care,” said Atul Grover, M.D., Ph.D., AAMC’s chief public policy officer, who moderated the event.

Level I trauma centers provide the highest level of trauma care. To receive a Level I verification from the ACS, these centers must be ready at a moment’s notice to respond to large-scale disasters. At the same time, they are responsible for a steady stream of patients with injuries caused by everyday accidents or gun violence. Level I trauma centers also play a major role in training future physicians.

The resources and mission of academic medicine make teaching hospitals an ideal location for trauma centers, according to Patrick Kim, M.D., trauma program director and assistant professor of surgery at the University of Pennsylvania Health System.

“Trauma centers are busy enough for residents to get exposure to major trauma regardless of what they end up doing in their careers,” Kim said. “If a teaching hospital does not have a trauma center, it’s very likely residents in some specialties will have to go to a Level I trauma center to get that exposure.”

In Tennessee, there are only a few Level I trauma centers. The trauma center at the University of Tennessee Medical Center often receives patients who require enhanced services that local hospitals cannot provide.

Blaze said...

@Victoria: I love old Senator Sanders and young Dr. Martin getting out the message that Canada's Conservative government has shown no indication to move away from a public, single pay system.

Ted Cruz, are you listening to your country of birth? That means if you want to move back here instead of foolishly renouncing Canadian citizenship, you, too, will receive excellent health care.

Oh wait. Ted, if you do that, Canadian banks and Canada Revenue Agency will FATCA you for the IRS. Better to stay where you are. (Even though Ms. Pike says "Canadians are very, very nice people.").

kermitzii said...

Victoria my middle kid age 20 got a summer job in Seattle with Facebook. I cannot figure out whether my insurance company (Sunlife Canada) would pay for hospital bills in Seattle or merely pay for ambulance/air to Vancouver (it does say that). They seem to be avoiding the issue so I will have to call them tomorrow along with another question. I cannot believe that even though I have my CLN I still have to deal with USA. Kermit

Victoria FERAUGE said...

@Tim, Very interesting. I didn't get the impression when I was in Boston (once) that it was unsafe. But then I was hanging around MIT so what do I know. In Paris and other places here some emergency services are managed by the firemen - the Pompiers de Paris, for example. I remember when France dropped the draft and my father-in-law (the former boss)wondered how no longer having draftees would impact the department and the delivery of services including emergency ones. I have a family member here who was years ago part of the pediatric emergency services in Paris.

@Kermit, Hey, my daughter is working in Seattle this summer too.

oliviadog said...

Hi there, I am a recent subscriber to your blog and LOVE all the topics I am exposed to and original ideas presented here. Such a good read!

I have often wanted to comment mostly with agreement or praise ... but this time I just wanted to add one tidbit regarding the Affordable Care Act as it relates to those of us living abroad.

Having no idea it would affect me, when I read your post I was aghast and totally freaked out! 330 days?!?! But as it turns out :

12. Are US citizens living abroad subject to the individual shared responsibility provision?
Yes. However, U.S. citizens who are not physically present in the United States for at least 330 full days within a 12-month period are treated as having minimum essential coverage for that 12-month period. ******In addition, U.S. citizens who are bona fide residents of a foreign country (or countries) for an entire taxable year are treated as having minimum essential coverage for that year******. (from

Sooo, that said, if I understand correctly - as I am a real resident of France, I don't have to shorten my trip to see Grandma this summer! But, I am very glad this was brought to my attention. Love your blog!

-Nicole (your fan from Saint Cloud, France)

Patrick said...

When the healthcare debate in the States was gearing up, it was very interesting to see all these people who never ventured out of the 'homeland', let alone had any direct experience of our NHS, giving really profound and insightful statements such as "your healthcare system sucks". My retort (other than "well, maybe our NHS isn't perfect, but your government really does suck") is that my two children were born under the NHS, one who is disabled and has been cared for by the NHS. I have had treatments by the NHS as well as my wife. I, unlike many in the 'homeland', have had direct experience with both US and UK healthcare systems. I know which one I prefer.

Tim said...

Being in Montreal for the weekend there are a couple of more things I thought of. One issue I have always had is that many "homelander" Americans who advocate a single payer system in the US don't know a lot about the Canadian system and don't have a clear idea of how they want to change the American system. For example the Canadian system is not a truly national system each province has its own administration of single payer and their are some significant differences.

For example Ontario has few pharma companies based in the province so the Ontario govt takes a very hard line on drug costs. Most of the rest of the "anglo" provinces follow Ontario to some degree. On the other hand Quebec has historically been the center of the Canadian pharma industry even post Bill 101 so the Quebec govt reimburses the pharma companies at similar rates to what the US HMO's do. Quebec also encourages doctors to prescribe brand name drugs unlike Ontario and the ROC where generics are more common. Now I suspect most American admirers of the Canadian Health System admire the Ontario version not the Quebec version. However, One cannot simply erase Quebec out of Canada nor can one assume that in areas of the US with a lot of pharma companies like Massachusetts and New Jersey there will not be similar pressure for Quebec treatment.

P. Moore said...

Another point worth is mentioning to these Senators about access. Some years ago, before Ontario started using a photo id version of the provincial health card with an expiry date, the Ontario government figured out there were around 1 million more Ontario health cards floating around than there were residents of the province. Who do you suppose were these 'phantom residents'? True, some were deceased or moved to other provinces, but the majority, it turned out to be were from nearby U.S. states! Even now, I am sure some of those are still in use since the old version of the health cards are still valid.

I guess these U.S. residents have been complaining about Canadian wait times.

Victoria FERAUGE said...

@Oliviadog (Nicole), Welcome to the Flophouse and thanks for reading and for the great comment. Ah, that does change things, doesn't it? Thank you for checking on that.

@Patrick, I have the same reaction whenever I hear someone from the homeland talking about the French system. Most of what I hear are sound bites for or against. And Tim is right - even the homelander who think they understand the French single-payer system clearly don't. It's a MIX of public/private. There are still insurance companies here and a lot of people use them in addition to the state managed coverage.

@P. Moore, Fascinating. Doesn't surprise me. Would you happen to have a link to a story about it?

P. Moore said...

That story is a little older than the time we had 'links', however, I remember it was the reason why Ontario changed to a photo id version of the health card with an expiry date and new requirements to prove a holder was a "legal" resident of Canada.

The old cards are still in use if anybody still has one, but any address changes etc. requires a new card. I understand there are still over 3 million of the old cards being used.

Anonymous said...

The reason Japan's health care system is criticized is because it is NOT good. I live in Japan and will let some of the newspaper article headlines speak for them selves.

Japan Times (JT) Sept. 04, 2007
A Medical Travesty in Nara
"In late August, a woman from Kashihara, Nara Prefecture, miscarried after nine hospitals refused to admit her. I August 2006, 19 hospitals refused to admit a woman, also from Nara, who had lost consciousness during delivery. She died eight days later after she gave birth in the 20th hospital."

JT Feb 05, 2009
Crash victim refused by 14 hospitals dies

JT May 06, 2008
Hospitals in Tokyo refusing flu patients

JT Apr. 12, 2008
Doctor shortage gives patients runaround

JT Dec 23, 2007
Doctor supply varies widely by prefecture

JY July 26, 2008
Hospitals need 1000 more ICU beds for babies, Ministry says

JT June 25, 2008
More Doctors Needed

JT Jan 31, 2006
Hospital death exposes tip of malpractice iceberg

JT June 05, 2008
Hospitals reused syringes on 10,000 patients

JT 29, 2009
Doctor scarcity hurting cancer care for women

JT Apr. 23, 2009
Shortage of rural doctors worsens

JT Aug. 3, 2009
Miscarriage rate found unexpectedly high
"More than 40 percent of women who have gone through pregnancy have experienced miscarriages."

JT Oct 30, 2008
Nearly half of perinatal centers short on full-time doctors* poll

JT Nov. 01, 2008
Obstetricians log 300-hour months

JT Feb, 24, 2009
8.3% of Tokyo emergency cases refused by multiple hospitals

JT Mar. 12, 2008
24,089 cases of multiple ER snubs last year

JT Dec. 29, 2007
30-hospital denial fatal to woman

JT Nov 15, 2008
82-year-old woman turned away by five hospitals dies

JT Nov 15, 2008
A Doctor in the house? Do you feel lucky
"After being turned away by eight Tokyo hospitals last month, a 36-year-old woman died after giving premature birth by caesarean section to undergo a brain operation. A month before, a 32-year-old pregnant stroke victim was bounced among six hospitals before one finally accepted her for treatment. She is currently reported to be in a vegetative state."

JT Oct 16, 2008
New round of health-care deductions riles seniors

JT May 22, 2008
New insurance plan ups burden on 'later-stage' seniors

JT Jun 27, 2008
Japan fatally behind curve on cervical cancer

JT Sept. 23, 2005
Breast cancer threat ignored

JTSept 30, 2010

JT Dec. 28, 2010
Bet on delayed response as ambulance calls rise, firefighters warn

JT Nov. 27, 2007
Less than 40% of adults get cancer screening

I have many more from other sources and more recent but they are in various external hard drives that my computer no longer is on speaking terms with.

The thing to remember in all these cases is that we in Japan pay for these services only to have them denied when we need them most.

Anonymous said...

The number of trauma centers in any given state really has no meaning. Unlike here in Japan, where they can not transport accident victims across 'state' lines we can and do in the States. When my niece was seriously injured in an auto accident on the highway that killed her mother, she was airlifted to a trauma center in a different state.

A ten year old boy, a neighbor of one of my students who relayed her experiences to me, was hit by a truck while crossing the street. The ambulance was on scene very, very quickly. Despite the extremely fast initial response, the ambulance sat on scene for 40 minutes. The boy's mother and neighbors pleaded with the ambulance to convey the seriously injured boy to the hospital just down the street, within view, in fact. The ambulance crew answered that they could not as that Hospital is in Tokyo and that they were in Chiba and thus were required to find a hospital that would accept him somewhere in Chiba. At last, a hospital accepted him but is was a 90 minute drive from the scene. Despite a hospital being just 5 minutes away, the injured had to wait for over 40 minutes for the ambulance crew to find a hospital within the same prefecture (state) and another 90 minute ride to get there.
Another reason I have nothing good to say about Japan's health care system.

My Niece would be dead if she suffered the same injuries in Japan.

Yet, even though the area of the state she was injured in was without a trauma center, a helicopter landed on the highway and wisked her away to a neighboring state where she was treated. My brother, her father, certainly does not have the means to pay for her initial treatment nor numerous after testaments which continue to this day a decade later. Yet she is treated and with us today.

Victoria FERAUGE said...

Wow, I had no idea. We were fortunate enough in our time in Japan not to need much in the way of health services...

Unknown said...
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