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US health care ranked last among 11 developed countries
June 17, 2014 4:32 PM   Subscribe

How the U.S. Health Care System Compares Internationally - "The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity." [full report (pdf)]

also btw...
-How Does US Healthcare Compare?
-Privatize The VA?
-A Healthy Sign For Obamacare
-Insurers flocking to ObamaCare
-Orszag: It's time for some optimism about health care spending
-Why Are American Health Care Costs So High?
-Third World Health Care - Knoxville, Tennessee Edition
posted by kliuless (71 comments total) 24 users marked this as a favorite

 
I don't know, I think it's way, way too early to judge our new health system. And when we do, the "obstacles to care" will largely be in states where the governors refuse to participate in expansion.
posted by roomthreeseventeen at 4:53 PM on June 17 [6 favorites]


It's a difficult comparison to make among nations given diet and other factors. That said the US is 35th in life expectancy while 9th in per capita GDP.
posted by vapidave at 4:53 PM on June 17


NHS! NHS! NHS!
posted by Bwithh at 5:02 PM on June 17 [4 favorites]


Good old American Exceptionalism.

I am reminded of an old episode of TV Nation, where they had three broken legs go through the ER in Canada, Cuba, and the US. As I recall, the Cuban ER won hands-down, but the network made them change it to Canada in the end.
posted by fifteen schnitzengruben is my limit at 5:02 PM on June 17 [4 favorites]


I'll bet we're #1 in insurance executive compensation, though. USA! USA!
posted by Faint of Butt at 5:07 PM on June 17 [20 favorites]


hey, the US does rank first in at least one category

granted, that category is "amount spent per capita" but still

number one, baby
posted by DoctorFedora at 5:17 PM on June 17 [1 favorite]


roomthreeseventeen: "I think it's way, way too early to judge our new health system."

If I've learned anything from our education policy, it's that it's never too early to undermine your most recent policy changes.

Fortunately, I haven't learned anything from our education policy because of our education policy.
posted by Riki tiki at 5:20 PM on June 17 [16 favorites]


Who are you going to believe, me or your lying eyes?

This is nothing but shameful. We Americans have an astounding ability to ignore and discount that which is right in front of us. It would be hilarious if it weren't so desperately sad.
posted by Benny Andajetz at 5:29 PM on June 17 [7 favorites]


I'm willing to believe that the US sucks ass in every way, but it seems like there's people in AskMe from time to time going "I'm in the UK/Canada/etc. so I can't see a specialist for 6 months"... Every time I need to see a doctor here in Chicago I call up and go in a few days or a few weeks at worst. Maybe I've just been lucky. I guess it's balanced out by the times I didn't have insurance and I didn't do anything.
posted by bleep at 5:29 PM on June 17 [1 favorite]


I'm an American who's lived in Japan for half a dozen years now and I still haven't gotten used to the idea that the procedure for seeing a specialist is essentially "call them and make an appointment."

And don't even get me STARTED on dentistry. Eleven bucks' equivalent to get a tooth drilled and filled with insurance, and EVEN IF I DID NOT HAVE INSURANCE it would only have been about $35.

The weird thing is, I actually see waaaaaay more competition in the medical field here in this nowhere nothing part of the country (I can literally walk to more than a dozen different doctors' offices of various types within ten minutes) than in the supposedly "competitive" US where I grew up.

Granted, it's also important to bear in mind that in the US, if you call it "lobbying," you get to not have to call it "government corruption."
posted by DoctorFedora at 5:37 PM on June 17 [20 favorites]


I'm willing to believe that the US sucks ass in every way, but it seems like there's people in AskMe from time to time going "I'm in the UK/Canada/etc. so I can't see a specialist for 6 months"

I think there's confirmation bias. I'm Canadian and when I think of healthcare AskMe's it seems like it's full of Americans who need to either A) Figure out how to pay a medical bill B) Find a doctor acceptable in some way to their insurance company or C) Deal with a troublesome insurance company. Never having had to deal with any of these problems (I never pay for care, I can see any doctor in the province and know it's covered, and I can't even imagine a situation where I'd have to call anyone about my insurance), it always seems odd to me that people aren't more morally outraged to have the problem in the first place (like deciding some doctors are "in-network' in the first place isn't just the most outrageous thing you can imagine).

I don't remember a single "I need to see a specialist more urgently than is possible" AskMe. I'm not saying they don't exist. I totally believe you that you've seen them. I'm just saying I think we notice the things that outrage/horrify/scare us.
posted by If only I had a penguin... at 5:50 PM on June 17 [25 favorites]


...but it seems like there's people in AskMe from time to time going "I'm in the UK/Canada/etc. so I can't see a specialist for 6 months"

And, those waits are almost always for non-critical, usually elective treatments. If you're in serious hurt in Canada or UK, and need to see a specialist, you can get in pretty quickly.
posted by Thorzdad at 5:50 PM on June 17 [13 favorites]


WE HAVE THE GREATEST HEALTHCARE IN THE WORLD!*

*Which we probably do. But you can't have any.
posted by uosuaq at 5:50 PM on June 17 [5 favorites]


If overtreatment of 10% while neglecting every conceivable metric for the remaining 90% can be considered healthcare then yeah, we're #1.
posted by hobo gitano de queretaro at 5:56 PM on June 17 [6 favorites]


Hey don't worry, USA, our latest Prime Minister wants to make the Australian health care system as broken as yours. Misery loves company, hey?
posted by nonspecialist at 5:58 PM on June 17 [8 favorites]


Ok, I'm still not saying you're wrong Bleep, but I just searched AskMe for "specialist doctor UK" and "specialist doctor canada" and "NHS specialist" and found no UK examples and one Canadian example, which appears to be from an American living in Canada who doesn't seem to know (is wondering if, among the other questions) they can just see a different specialist instead.

Searching AskMe for "US Health Insurance" gets over 400 hits. Not all of those people are necessarily in the categories that I listed above, but I'm guessing it's not common to ask questions about your health insurance unless you're having a problem with it.
posted by If only I had a penguin... at 6:00 PM on June 17 [4 favorites]


I think there's confirmation bias

The data on Canadian healthcare implies otherwise.
posted by roomthreeseventeen at 6:00 PM on June 17


We're number 1....1! We're number 1....1!
posted by Naberius at 6:07 PM on June 17 [4 favorites]


In New Zealand I have a six year old daughter and when we had her money was never even mentioned, even though it was a fairly medicalised birth that ended in a Caesarean (she had thoughtfully wound her cord like three times round her neck, no way she was coming out anyway but the sunroof). I feel very, very lucky.

In practice most people get a reasonable response time from public and pretty good care, and you can drop the $$ and go private if you want to jump the queue.

Also of interest: ACC and Pharmac. Pharmac is under threat from the TPP because it buys good drugs incredibly cheaply and embarrasses the drug companies. (<= tendentious but mostly accurate reading)
posted by Sebmojo at 6:08 PM on June 17 [4 favorites]


USA! USA! USA!
posted by Our Ship Of The Imagination! at 6:08 PM on June 17


Room, that doesn't say anything about questions posted on AskMe, which was the topic I was addressing.

Same day appointment stat in the article. What's the denominator there? If the quesiton is can you see your regular doctor the same day, are people who don't have a regular doctor (in either country) in there? Also, nothing in the article supports the headline (the headline may be true, but the article doesn't give average times to see family doc). The article also says nothing about specialist access, which was the topic of the AskMe topic. I'm ready to believe it takes longer in Canada if you remove from the sample people who can't see a specialist at all. It's just not in the article.
posted by If only I had a penguin... at 6:09 PM on June 17 [1 favorite]


"I'm willing to believe that the US sucks ass in every way, but it seems like there's people in AskMe from time to time going "I'm in the UK/Canada/etc. so I can't see a specialist for 6 months"... Every time I need to see a doctor here in Chicago I call up and go in a few days or a few weeks at worst. Maybe I've just been lucky. I guess it's balanced out by the times I didn't have insurance and I didn't do anything."


There is some legitimacy to this. I'm from the US and was married to a Canadian. In Canada you essentially audition for a GP and they may or may not accept you as a patient. My Mother-in-Law spent a week in a bed in the hallway of a hospital while being treated. My Uncle-in-Law went to Minnesota to get treatment for a heart condition. He had money. Still, on average, health care is better in Canada.

It's better to be of average means in Canada than it is in the US. If you have a bunch of money the US is the place to go for heroic health care.

I was watching golf this weekend and there was a man who had recieved two heart transplants.
posted by vapidave at 6:10 PM on June 17 [3 favorites]


Unfortunately the stakes are higher, but with healthcare in the US I treat it like arguing on the internet. At this point everyone here has been told repeatedly for twenty years that we do it expensively and stupid, but if they aren't convinced by the third time it's never going to happen. Sometimes people just need to be wrong.

And a significant part is that a lot of people (like myself) have good healthcare access. We have a shitty system but individually things can be decent.
posted by Dip Flash at 6:13 PM on June 17 [2 favorites]


Also, nothing in the article supports the headline

it's the Huffington Post. They have a rule about that.
posted by Kirth Gerson at 6:24 PM on June 17 [4 favorites]


I don't like arguments to the effect that if everybody had access to decent, minimum healthcare, we'd all have to wait forever. I've never heard a single person say that we should all have access to decent, minimum healthcare, *and* even if you can afford it, you shouldn't also be able to pay extra for quicker, better, gold-plated healthcare. Please do so! You'd be reducing wait times for the mere humans who might otherwise muck up your beautiful existence.
posted by uosuaq at 6:26 PM on June 17 [2 favorites]


From the article:

The Affordable Care Act is increasing the number of Americans with coverage and improving access to care, though the data in this report are from years prior to the full implementation of the law. Thus, it is not surprising that the U.S. underperforms on measures of access and equity between populations with above- average and below-average incomes.

Um, this seems like a fairly important point.
posted by Slarty Bartfast at 6:29 PM on June 17 [7 favorites]


I have been waiting 3 years for what should be routine cancer monitoring scans. I live in a city with more MRI and CT machines than most Canadian provinces combined. Due to my HMOs, I haven't been able to see a new oncologist once mine relocated. I've been flipped more than half a dozrn times through HMOs and Medicare, each one passing me on to the next when the costs got too high.
Guess what - disabled people have high healthcar costs, shocking!
After 6 months of trying, I had an oncologist (not in my specialty, but at least an oncologist at all) appt yesterday, and after reviewing my history it consisted of him yelling - as in raising his voice repeatedly - while on the phone with my HMO's radiology bureacracy. Had my first scan today and clinic tried to bill me for it. Will be intereting to see whether the very technical/$$$$ scan on a few weeks happens, or whether as all the times in the past it's cancelled by my current HMO.
I can't afford much for a healthcare att'y, and recently when looking for one anyway, found out no one in-state knows the evolving new ACA implementation laws. Not are the HMOs keeping their procedures handbooks up to date - i've internal appealled and appealled, and then after 2-3 refusals and several months for every treatment request, am mysteriously tranferred to another HMO. Every month is a lottery for which medications will be filled.
If I'd had surgery to remove the primary tumor when diagnosed 8 years ago - probably would be back to work (or more likely looking for work and unable to afford insurance) FT. Now - metastastes all over. Good thing they're very slow-growing.
Best healthcare in the world my cancerous ass.
posted by Dreidl at 6:30 PM on June 17 [30 favorites]


I know the insurance system is a clusterfuck, I'm just saying it seems like if you actually need to see a doctor it's easy to. I've never had a problem seeing a doctor for anything ASAP. The problem is paying for it; insurance companies don't pay for shit (ask me how I know) and then you go bankrupt. Whereas it seems to be the opposite in other places, you just get your punch in the face on the front end instead of the back end. This is just my impression, confirmation bias could be a factor. That's why I was surprised to see the UK Number 1 for everything. (I'm not a fan of the US system or advocating for it, if anything I'm a victim of it.)
posted by bleep at 6:32 PM on June 17


I am reminded of an old episode of TV Nation, where they had three broken legs go through the ER in Canada, Cuba, and the US. As I recall, the Cuban ER won hands-down, but the network made them change it to Canada in the end.

I recall it as well, and (though Canadian) I saw it on an American station. The Cuban had no charge; the Canadian paid fifteen bucks for the crutches but nothing else; and the American was handed a lengthy bill adding up to the low four digits is my recollection.
posted by ricochet biscuit at 6:34 PM on June 17 [1 favorite]


Commonwealth Fund? A bunch of elitist New York Doctors can't tell ME anything about healthcare just because they are so-called 'experts'! At least here in the US I don't need to wait around for months to see a doctor like they do in the Peoples Republic of Canada, here we have the freedom to die without access to proper care for completely preventable illnesses! At least I have the choice of going bankrupt due to medical bills whose pricing structure is made up out of thin air because procedures literally do not exist in any kind of market system whatsoever. I'm saving so much money because I don't have to pay for some other guys medical procedures - which in my fantasy world are always within the realm of human control. With the tax money I save I could literally buy a few lunches! Good thing I am so personally responsible that I will never get sick...because I'll tell you, when I become a millionaire through plucky hard work and determination I'm going to get the best care ever. I will definitely become a millionaire before I get sick because USA!


*In many parts of the US, parts or the whole of the above commentary are not viewed entirely as sarcasm...the fact that there can be no outrage over our healthcare system is almost more enraging than the system as it stands.
posted by jnnla at 6:36 PM on June 17 [7 favorites]


I think the paying for it is an important point tho.

If you go to a doctor you thought was in network and turns out they're not, you're on the hook most likely.

So while it may be easy to actually get in, many people are wary. It's often NOT easy to find what doctor or practice is in network. And that info can mean the difference between $20 copay and $2500 bill.

People in Canada and UK I'm fairly certain don't have this problem. (Please correct if wrong)
posted by sio42 at 6:36 PM on June 17 [1 favorite]


My suspicion is that quality of care and cost measures are going to significantly lag behind after implementation of the ACA. My fear is this will be fodder for people who are waiting to call obamacare a boondoggle. There is no question that access to care has dramatically increased. Our office is being *swamped* with trying to play catch up with deferred care. Since the first of the year I've seen dozens of people with advanced disease, metastatic cancer, etc who never considered seeking care for that nagging symptom they were hoping would go away. From a statistical analysis, this year is going to see a whole ton of "new" cancer diagnosis with all of the associated costs and for the next couple years we are going to look like we suck at keeping people healthy and spend even more money doing it.

I'm no apologist for Obamacare. Health insurance companies are downright evil, when they aren't incompetent, and since the first of the year it feels like they've become much more aggressive about "controlling costs" ie denying payment for things. I've started sending people to ERs for things that I can no longer argue against insurance companies to get authorized. At least there, it gets done.

My advice is that if you are USian and it feels like your insurance company is screwing you, they probably are, and getting rich doing it. And your physician is probably powerless to do anything about it.
posted by Slarty Bartfast at 6:46 PM on June 17 [18 favorites]


I bet the US system generates the most profit, though.
posted by ceribus peribus at 6:54 PM on June 17 [5 favorites]


Anyone who thinks we don't have to wait to see a specialist in the US has never tried to make an appointment with a rheumatologist. That is a minimum 2 month wait in every city in the US I've ever heard of, and frequently it's more like 3 or 4 months. Yes, these are chronic conditions that are not going to go away in those intervening months. But in the meantime, while waiting to see a specialist, people keep feeling like absolute crap and being progressively disabled by their condition.
posted by hydropsyche at 7:03 PM on June 17 [5 favorites]


I know the insurance system is a clusterfuck, I'm just saying it seems like if you actually need to see a doctor it's easy to. I've never had a problem seeing a doctor for anything ASAP. The problem is paying for it; insurance companies don't pay for shit (ask me how I know) and then you go bankrupt. Whereas it seems to be the opposite in other places, you just get your punch in the face on the front end instead of the back end. This is just my impression, confirmation bias could be a factor. That's why I was surprised to see the UK Number 1 for everything. (I'm not a fan of the US system or advocating for it, if anything I'm a victim of it.)

You are right to a certain extent. The way the NHS keeps costs down is not having more resources than it needs. For most non-emergency medicine patients must first go to their GP who will diagnose and treat, or refer to a specialist. It means that many minor ailments, chronic illnesses, and timewasters, can be seen by the same general doctor. If you are referred you will be given an appointment some days, weeks, or even months ahead, according to need. Thus rather than see everybody equally quick by having specialists ready and waiting, the same specialist can manage their appointments by prioritizing.

For example, the same surgeon at my local hospital performs hysterectomies for womb cancer and removal of endometriosis cysts. Those with cancer get seen sooner than those with cysts, and the latter might get their appointment shunted for a cancer patient. Everybody gets seen in decent time, but there's a recognition that need comes first. It's better to put somebody with endometriosis on painkillers for another few weeks than to delay the removal of cancer.
posted by Thing at 7:05 PM on June 17 [5 favorites]


I know the insurance system is a clusterfuck, I'm just saying it seems like if you actually need to see a doctor it's easy to.

Seeing a doctor is entirely a different matter than getting diagnostics or treatment paid for.

Hell, I've had cases where I've been able to tell people what's wrong with them using nothing more than my stethoscope but that literally means nothing to insurance companies. Seeing a doctor means nothing if you don't have X test showing in black and white what you've got and it's pretty easy to delay or refuse the performing of test X. And course they won't pay for treatment Y without a positive test X. Voila, problem solved.

Ask Me Anything, I'm a doctor on the front lines of the great HMO War.*

*not really, I'm about to go out for a few drinks. My doctor says it's ok, my abdominal CT wasn't covered so I couldn't possibly have cirrhosis.
posted by Slarty Bartfast at 7:06 PM on June 17 [6 favorites]


My suspicion is that quality of care and cost measures are going to significantly lag behind after implementation of the ACA.

The ACA, unfortunately, does very little to address the out of control costs of health-care - outlined very well in this article by Steven Brill.

Because there is no regulation of procedure pricing outside of Medicare / Medicaid, each and every hospital charges arbitrary amounts for the same procedure - usually 3 or 4 times what it might actually cost - because insurance companies will only pay out 1/3 or 1/4 the price per procedure.

This is why on US medical bills it will say something like:

Chest Xray__Cost: $2700__Adjustment: -$2100__Liability: $600

Then depending on your coverage the insurance company will cover 'X' amount of that liability. As far as I, or anyone really, understands, the magic adjustment has absolutely no basis in any sort of economic reality whatsoever. It is totally arbitrary, as is the procedure cost created by the hospital chargemaster. It's madness and answers are very hard to come by when trying to poke around inside the system.

If you are paid for by Medicaid / Medicare...however...each procedure has a code with an agreed upon price and that is what the gov't pays the hospital. Is it less money than a private insurance payout? Potentially. Is it closer to what the procedure ACTUALLY COSTS - yes.

I also fail to see how my employer-subsidized HMO healthcare scheme gives me any sort of real freedom when the doctors I can see are dictated to me by a list...and that list of doctors all have terrible scores on health-grades / yelp. The doctors I have access to reads like a list of the worst doctors in Los Angeles...although I am very cognizant that that is better than no care at all...and I am thankful for that because I have been denied care in the past.
posted by jnnla at 7:12 PM on June 17 [2 favorites]


I'm a USian who spent 2 years with the UK NHS and have spent a month with the Australian Medicare system (though I'm pregnant so I've been to more appointments in this last month than my two years in the UK). Have to say, no complaints in either non-US country so far, other than the nurse who didn't use lube on the speculum for a pap smear in the UK and told me it was my fault it hurt. In both countries I've been able to get appointments quickly, never paid a cent in the UK (except for prescriptions, for which pharmacists apologized to me profusely that I didn't qualify for free prescriptions), and here in Australia doctors list their fees on their websites or will tell you on the phone no problem so you can comparison shop -- something that, as an American, continues to shock me every time, as I'm not sure I've ever been aware of how much a single medical appointment or service has ever cost before in my life. Even though there's a fair bit about the combination public/private Australian system that I think doesn't entirely make sense, generally speaking, I've been very happy and impressed so far, including with the public hospital I'm going to for my prenatal care (who actually worked it out so I can have the same midwife for all my appointments, which addresses one of the usual complaints I've heard about the public system).

Granted I don't have major chronic conditions and I haven't had any major needs for specialist surgery, and I know people who, say, have a back problem that the Australian system has deemed "not urgent" so he would have to wait ages to go through the public system to have it addressed. That sucks. But I think what most anti-socialized-medicine Americans don't understand is that in both these countries, if you have the money to pay for it, you can pretty much always get what you want when you want it. The fear of the wealthy that the unwashed masses will somehow knock them to the end of the queue is really unfounded. Of course, this still makes for an unequal system, politicians can continue to avoid eating their own dog food, etc, and that's not really cool. But providing a good quality minimum level of support to all your citizens, and still allowing special treatment for those who can afford it, seems to me much better than screwing a significant percentage of your citizens and still allowing special treatment for the wealthy.
posted by olinerd at 7:12 PM on June 17 [4 favorites]


We have the greatest healthcare *Profit* in the world! and that's what's really important.
posted by theora55 at 7:26 PM on June 17 [1 favorite]


I'm not surprised that US is 11th amongst these 11 countries.

I am fairly surprised that Canada ranked 10th.

My interpretation of these data are that the upshot of the US's problem is spectacularly huge costs brought on by spectacularly large bureaucracy brought on by a spectacularly stubborn political philosophy of not allowing any cost controls or transparency because of the god-damned free market.

Canada's problem is being understaffed.

On this general subject, I highly recommend the book Healing America. It's a survey of all the healthcare models amongst the developed world (as well as the rest of the world, aka "out of pocket"). The take home quote from it was memorable for me: "Every healthcare model has issues, it's just the U.S. has the worst one"
posted by mcstayinskool at 7:30 PM on June 17 [3 favorites]


If you are paid for by Medicaid / Medicare...however...each procedure has a code with an agreed upon price and that is what the gov't pays the hospital. Is it less money than a private insurance payout? Potentially. Is it closer to what the procedure ACTUALLY COSTS - yes.

I'm paid primarily by Medicaid now, in fact I left private practice for many reasons, but one of them was to get out of this maddeningly byzantine payment scheme that pits layers of physician/bureaucrats against layers of HMO bureaucrats. For years, Medicaid was simple. We knew what things cost. It was low, but we knew what it was and we didn't need an army of billing staff to make sure we got what we expected. The magnificence of the ACA is that Medicaid in Washington state was expanded but also subcontracted out from the state to one of five private insurers (only 2 of whom had experience with Medicaid populations and worked non profit), so patients on Medicaid, many of whom are disabled, newly immigrated, non-English speaking, cognitively impaired, or under educated get to choose, because, you know *capitalism* and *competition*! So like everyone else, we now no longer have a set agreed upon price for services across the board, but different prices and agreed upon "discounts" depending on the contract with the insurer.

I feel like standardization of fees would go a long way to reducing costs, but this will never happen because HMOs will feel that this takes away their negotiating power to control costs on their own, and lets face it, if everything is more or less covered the same, what's the point of having private companies administer this in a dozen different ways?

Maybe thats the next step towards single payer. Regulation of fee structures. That would be the thing to get buy in from hospitals and physicians -- you won't need to guess what you're going to get paid and you won't need several dozen coders to defend your fee.
posted by Slarty Bartfast at 7:33 PM on June 17 [8 favorites]


It's a difficult comparison to make among nations given diet and other factors

Yeah true, but this isn't comparing outcomes necessarily, it's looking at measurements on a number of different dimensions like "[patient h]as chronic condition and did not receive recommended test, treatment, or follow-up care because of cost" (where the US came last) or "Doctor or other clinical staff talked with patient about a healthy diet and healthy eating" (where the US came first); "Patient given wrong medication or wrong dose at a pharmacy or while hospitalized in past 2 years" (US came 9th), "Primary care physician always or often receives notification that patient is being discharged from hospital" (9th); "[hospitalized patients] Received clear instructions about symptoms to watch for after leaving the hospital" (1st).

The full report is pretty interesting in digging down to these different factors (whether they are the absolutely correct ones to be measuring is maybe a different question, of course).
posted by Pink Frost at 7:35 PM on June 17 [1 favorite]


I don't like arguments to the effect that if everybody had access to decent, minimum healthcare, we'd all have to wait forever. I've never heard a single person say that we should all have access to decent, minimum healthcare, *and* even if you can afford it, you shouldn't also be able to pay extra for quicker, better, gold-plated healthcare.

But I think what most anti-socialized-medicine Americans don't understand is that in both these countries, if you have the money to pay for it, you can pretty much always get what you want when you want it. The fear of the wealthy that the unwashed masses will somehow knock them to the end of the queue is really unfounded.

The above mentioned arguments that somehow socialised medicine will reduce choice is something I see again and again in debates on US healthcare, and it's baffling.

Here in New Zealand I have the following healthcare options:

a) If I'm involved in an accident, my medical and rehabilitation costs are covered by ACC [An automatic no-blame insurance system] - also covers stuff like in-home help during recovery etc.

b) The public healthcare system provides free heathcare on a prioritised basis i.e. non-urgent stuff gets handled non-urgently.

c) I can choose to get treatment privately via insurance cover provided by my employer.

d) I can choose to get treatment privately and pay for it myself.

Nothing in a socialised system precludes the option of insurance and/or private treatment. Why would you not want it when it will cost you less?
posted by HiroProtagonist at 7:42 PM on June 17 [4 favorites]


I just wanted to add a point about problems deemed not urgent, that may not be clear to Americans. There is no process in Canada (and I suspect no process in other countries) whereby "the system" deems a problem non-urgent. Nor is there a system of waiting lists. That whole layer of administration just doesn't exist. It seems to exist to some extent in US insurance companies where there's some bureaucrat who runs you thorugh a flow-chart to see if you qualify for this or that test or procedure (this horrifies me not just because some bureaucrat gets to make healthcare decisions for you, but also because no one seems to care about the privacy violations -- why should your insurance company even have access to to your health information? but I digress...)

Anyway, the urgency or non-urgency of your problem is decided by the treating doctor who can see you and treat you sooner or later as per their own judgement/availability. It's not that someone in the government has decided who goes first, it's ultimately something that happens when you make the appointment. The same goes for "waiting lists." there is no "list". There's a first appointment that the doctor will slot you into. They leave open slots in case urgent things come up (which will then go in the immediately available slot). If the doctor doesn't think your problem requires the immediately available slot, then your appointment is later. Different doctors have different scheduling practices, different priorities, different populations of patients and are differently popular, so it's possible that an appointment you would wait time x for with one doc would be 2x or 1/2X with another. And of course, you're always allowed to switch doctors if that's what you want. Nowhere is there some centrally manged body determining how urgent your case is or how long you have to wait.

Incidentally, I've never heard of doctors auditioning patients. What is true is that doctors who have "enough" patients just don't take new patients. That's so they can see their existing patients often enough/for long enough/without waiting etc. It is a problem for people who live in places with not enough doctors accepting new patients, but doctors are private practitioners and can do as they please. My doctor isn't accepting new patients, and I can always get a same day appointment to see her, and if I don't feel like I need to actually go in, she's happy to talk with me on the phone if I need to consult. But if I want an appointment for a physical, it's usually 2 months out -- that's to keep lots of slots in the schedule open for people who need same day or within a few days appointments. I've had the same doctor since I was 10, which is now more than 25 years. I can't imagine a system that would make me switch due to a job change or network change or whatever else it is dictates Americans' choice of doctors.
posted by If only I had a penguin... at 7:42 PM on June 17 [8 favorites]


There is a wonderful article on the New Yorker blog: on "Why America is losing the health race" by a well-respected canadian internist.

He makes the argument that about poverty, and income inequality, and the role it has on all Americans:

"... even white, college-educated, high-income Americans with healthy behaviors have worse health than their counterparts in other wealthy countries."

And also, of course, "we are the shining light on the hill" ignorance:

Whatever the political obstacles, a major explanation for America’s persistent health disadvantage is simply a lack of public awareness. “Little is likely to happen until the American public is informed about this issue,” the authors of the NRC-IOM report noted. “Why don’t Americans know that children born here are less likely to reach the age of five than children born in other high income countries?” Woolf asked. I suggested that perhaps people believe that the problem is restricted to other people’s children. He said, “We are talking about their children and their health too.”
posted by cacofonie at 8:03 PM on June 17


American here. Lucky enough to have had full medical insurance for a decade and to live in an area with plenty of doctors and a large University Medical Center. "Specialist" covers a wide variety of roles. There are plenty of "specialists" I could get in to see within a few days. Anything routine really. But the first time I needed someone very much not routine, well those specialists have waiting lists six or eight months out.
posted by tyllwin at 8:16 PM on June 17


Glad to be living in Japan every time I read a report like this or hear of another shooting. Affordable health care for me and my family, and we ain't gonna get shot, neither.

now if they'd just stop with the gaddam earthquakes...
posted by flapjax at midnite at 8:28 PM on June 17


Yeah, access to specialists may depend ENTIRELY on what city you're in. When I needed to see a dermatologist while living in small town Alabama, there were a total of 3 in a pretty sizable area and it was a 6 month wait to get into the 1 that was accepting patients.
posted by Ghostride The Whip at 8:30 PM on June 17


I don't know, I think it's way, way too early to judge our new health system.

Even though from the US perspective, the ACA feels like the changiest change ever to change (I feel you! I live here too), I think it would be kind of chauvinistic to claim that we have initiated a "new health system" in any kind of research-relevant sense. Stripped of the political circus and the massive gridlock in getting the thing passed, the ACA is, well, some changes to the law regarding healthcare. I'm sure Norway, Germany, or the UK have these sometimes too.
posted by threeants at 8:42 PM on June 17


get a tooth drilled and fillled with insurance

They use strange materials over there... :-)
posted by smidgen at 8:49 PM on June 17 [2 favorites]


I don't know, I think it's way, way too early to judge our new health system.

Probably so. All I know is that my experience this year has been fairly horrific. I had employer-sponsored healthcare in the past, and now I work freelance and bought insurance myself through my state's insurance exchange. Because of the new system, I can't switch insurers even though numerous things have gone wrong (including my insurer accidentally canceling my insurance, which I discovered when I was incredibly sick and trying to go to the doctor). All in all, I'm really, really unhappy. I'm paying out of pocket now to take care of some urgent issues.
posted by three_red_balloons at 8:51 PM on June 17


(To add a bit more detail, I think all of the problems with my insurer have been caused by the fact that they have been overwhelmed by the number of customers they now have...it's been a problem since the beginning, when they couldn't answer their phone because they were getting tens of thousands of calls a day. They accidentally cancelled my coverage because of an administrative error, and it took me 3+ hours on the phone to get that sorted out. Without going into more details, I'm totally unsatisfied with my coverage and want to take my business elsewhere, but I can't. Now I'm just paying doctors directly and racking up huge bills).
posted by three_red_balloons at 9:10 PM on June 17


Oh, right. I should probably also add as an addendum, Japanese single-payer costs about $200 a month if you have to go out-of-pocket (like if it isn't covered by your employer) and covers 70% of whatever the real cost of a procedure is.

It's a pretty good system overall that could basically never happen in America.
posted by DoctorFedora at 9:25 PM on June 17


And don't even get me STARTED on dentistry. Eleven bucks' equivalent to get a tooth drilled and filled with insurance, and EVEN IF I DID NOT HAVE INSURANCE it would only have been about $35.

The problem with dentistry in Japan is that dental work that would be taken care of in a single visit in the US is unnecessarily spread out over several visits because clinics get reimbursed per patient visit. That's the whole reason patients can get by only paying a few thousand yen for large procedures. It benefits dentists to see more patients for smaller amounts of time, so cleaning and other procedures are all done on separate visits, and work is rushed so that the dentist can get to the next one of the 30 people waiting in the lobby.

Oh, and the quality. I have walked out of more than one dentist office in japan after seeing dentists treat patients without gloves, not change gloves between patients, etc.

I don't know what the solution to the US problem is, but I don't think the Japanese system is an ideal model of a better alternative.
posted by Kevtaro at 9:34 PM on June 17


Ok, I'm still not saying you're wrong Bleep, but I just searched AskMe for "specialist doctor UK" and "specialist doctor canada" and "NHS specialist" and found no UK examples and one Canadian example, which appears to be from an American living in Canada who doesn't seem to know (is wondering if, among the other questions) they can just see a different specialist instead.

As the person who posted that question, I wanted to respond. I am not American, but have lived there (always luckily with good insurance). I'm Irish and have experience of the Irish, UK, Danish and Canadian systems. Anyone who doesn't think there are issues with wait lists in Canada is either very lucky or has faced a different system than I. Once before, when faced with another 9 month wait to see a specialist for a very painful (though not urgent as in the sense of life-threatening) foot problem, I ended up paying to go to a private specialist and having the surgery done privately.

Don't get me wrong: I love the way that in Canada everyone is covered and you can go see many doctors by just showing your card, and I really did not like the US lottery system where healthcare was great for me with my great health insurance and crap for those without insurance or with terrible insurance. I would rather this system than a private model one as operates in the US. But it is a system that just handed me a 6 month wait to talk with a specialist to talk over the results of a year long series of tests. I'm not an urgent case as in I'm not dying, but I sure feel grim and am, I suspect, going to have to take time off work at some point during that 6 month wait because this condition is severe enough to affect my ability to work. It took 4 months just to see the specialist's locum in the first place, so I know that even if I go back into the system I will be waiting. I worked with someone who had an inner ear problem that had a very similar experience- right up until the point that someone thought that maybe they had a tumour and this experience should be sped up. And then the system went into overdrive.

Obviously my experience is not everyone's and (at least in my view) I did draw the short end of the stick here, but I think pretending that a public health care system is not going to have to do this sort of thing and ration care to some degree is not exactly useful. It's a fairer system and works better, but it's not very much fun if you're the person waiting sometimes years and years for care (that's in Ireland, though, where wait lists are insane).

And don't get me started on the near impossibility of getting a family doctor in Vancouver.
posted by lesbiassparrow at 10:26 PM on June 17 [2 favorites]


Wow, it is really sad to see that Canada has dropped to 10th out of 11th. Dammit.
posted by Canageek at 10:29 PM on June 17 [1 favorite]


And I just noticed that in the report Canada ranks 10 in regards to timeliness of care, which both comforts (I haven't been picked out to suffer!) and doesn't surprise me. Am surprised that it ranked so low on equity, though.
posted by lesbiassparrow at 11:11 PM on June 17


In the UK we have the opposite problem to the US, by which I mean in the US (it seems to me) the main problem in reforming your health system is the media constantly telling people it is the best in the world when it is in fact pretty terrible for a lot of people.

In the UK the media is constantly telling us that the NHS is a terrible system, falling apart, underfunded and full of murderers. So we absolutely have to privatise it all.
posted by Just this guy, y'know at 12:31 AM on June 18 [14 favorites]


A case in point here.

There is a constant stream of articles like this looking for ways to introduce a tiny charge here or there, because as soon as there is a charging mechanism somewhere it can be expanded and expanded.

"Andy McGovern, a hospital nurse in London, said he would propose a motion calling for fixed fee to see a GP. Research suggested anything from 57p to £10, he told the Daily Mail. "We need to have a robust and honest debate about what we're going to do in the future because the money isn't there," McGovern said."

We need continuous and repeated reminders that the NHS is the cheapest system with some of the best outcomes, because it's enemies would have everyone believe that the NHS is bankrupting the country.
posted by Just this guy, y'know at 3:36 AM on June 18 [7 favorites]


Sorry to triple post, but to further underline my point here is more news from today.

NHS 'facing funding gap of up to £2bn' in England

This article even cites the commonwealth report (before pretty much ignoring it) and uses the phrase 'Honest Discussion' again (as used in the previous linked article), which I guess is this season's codeword for selling bits of the NHS.
posted by Just this guy, y'know at 4:23 AM on June 18


Wow, it is really sad to see that Canada has dropped to 10th out of 11th. Dammit.

Eight years of the Harper government will do that to you. Canada has a great system - the fact that it's still operating at all after eight years of its own government trying their damndest to destroy it speaks to how robust it really is.

Yeah, Canadians love to bitch about their health care system and point to the occasional glitch or failure that any system will have and scream that the whole thing is collapsing. When I lived there, I would quietly point out a few elements of healthcare in the U.S. (e.g., middle aged men routinely using home pregnancy test kits to try and figure out whether they had prostate cancer and should really start saving for a doctor) and they tended to shut up.
posted by Naberius at 7:03 AM on June 18 [1 favorite]


"I'm in the UK/Canada/etc. so I can't see a specialist for 6 months"

If your condition is non-urgent, you're going to (as explained above) get the first appointment that isn't being reserved for people who need to see that specialist as a matter of life or death.

We make mistakes. We do. Nobody intelligent pretends otherwise. But in basic terms the entire Canadian healthcare system functions the same as a decent ER: the most urgent (bleeding, dying, what have you) cases get seen first. The less urgent (cut myself bad enough to need stitches but the bleeding has basically stopped, broken arm) get seen later. Prioritization is a thing that matters in healthcare, and if the wealthy don't want to wait they can go to one of a (very few) private clinics, or more likely just hop across the border and jump the queue that way.

Eight years of the Harper government will do that to you. Canada has a great system - the fact that it's still operating at all after eight years of its own government trying their damndest to destroy it speaks to how robust it really is.

This. Oh and Harper just cut $36bn (!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!) from the healthcare budget. Plus, yeah, chronic understaffing is a major problem; doctors here can either choose to make a (really damn decent, upper middle class if not low to mid upper class) living here, or they can move to the USA into private practice and make gobs and gobs of money. Guess which one more doctors--especially specialists--and nurses choose? That's our real problem. The doctors that stay are by and large the good ones, the ones who truly care about healing sick people and not the size of their bank accounts. Hell, my GP volunteers several evenings a week at the Hassle Free Clinic, a sexual health clinic located downtown. (Torontonians: they're absolutely great there, not an ounce of judgement about anything anywhere, and offer anonymous rapid HIV testing--the only procedure for which you need an appointment. Everything else is purely drop-in. They also have separate hours for female-identified and male-identified patrons, both for everyone's comfort and to staff and equip accordingly.)

But that we're down to #10 is distressing on a really, really deep level.
posted by feckless fecal fear mongering at 9:09 AM on June 18


I'm willing to believe that the US sucks ass in every way, but it seems like there's people in AskMe from time to time going "I'm in the UK/Canada/etc. so I can't see a specialist for 6 months

This can happen depending on where you live. I developed a food allergy a couple of years back and it took 9 months to get an appointment with an allergist. The appointment turned out to be a waste of time because that skin test didn't work on me, even the control ones.

But if it's an emergency, they will generally get you seen quickly.
posted by Hoopo at 9:52 AM on June 18


everyone in the world loves grumbling about their healthcare. For me, it's a job.

But recently at work I had a strange rash after my doctor's closing hours and called ER. They said I needed to call the number my doctor said on his answering machine and I did. The nurse there said: will you please get out here immediately. We close at 4PM, but will stay open for you.

When I got there 4:01, they were super professional, told me the (serious) possibilities, and took all the relevant tests. I also got the relevant prescriptions which were sent immediately to the pharmacist. Luckily, it turned out I had the least terrible ailment out of the three really bad options they lined up for me. But I was so impressed by how fast they reacted and by the difference between having a common flu and just needing a doctors statement for job-insurance purposes (my usual reason for calling the doctor), and then being potentially seriously ill.

Obviously, this is not America. But it is an example of how not-US healthcare systems do it when they prioritize.

My doctor shares burdens with colleagues in his district. But he will also do home-visits and take in patients after hours on most days. If you just need a vaccination, his intern will do it, and sometimes that sucks. But basically, I feel I get a lot of value for my tax-money. Until quite recently, I had a co-pay program, because my doctor lived in the neighboring district to where I live. But they changed the system so I now have freedom of choice beyond the districts. This also means that healthcare is "free" (payed over taxes) when I am in my summer house, where I had to copay before. Socialism is nice…
posted by mumimor at 10:48 AM on June 18


I've had the same doctor since I was 10, which is now more than 25 years. I can't imagine a system that would make me switch due to a job change or network change or whatever else it is dictates Americans' choice of doctors.

I'm a Canadian living in the US. I got a job at a hospital because they have the best insurance for their employees available in Tennessee (or did when I started working here, I haven't compared recently) and in the hopes that working in healthcare would help me navigate the system (which it has - mostly because I understand it better but partly because the doctors I work for can provide some basic "do I need to officially see a doctor" triage for me outside the system).

The difference between seeing a doctor in network and seeing a doctor out of network can be very minor or can be huge. My PCP (general practitioner to Canadians) costs me $15 more per visit because he's out of network, and I don't care about that. But I have a minor outpatient surgery coming up and am waiting to find out if my insurance will cover it with my in-network-for-some-things-but-out-of-network-for-others-I-don't-know-why specialist. If they won't cover it I will need to find a surgeon who is in network who can do it, because I don't have $1,000 lying around that I'm not using.

It can be very confusing knowing what and how much things cost and who you can see without going bankrupt.
posted by joannemerriam at 10:55 AM on June 18


Zombie arguments defending the US healthcare system
There’s a new Commonwealth Study that ranks the US pretty poorly. Nothing new there. Nothing new to some of ways that people defend the US. So let’s dispense with them in rapid fashion.
posted by the man of twists and turns at 12:27 PM on June 18


I got this.

Free markets *something, something* welfare hurts poor people *something, something* not everyone deserves medical care *something, something* emergency rooms *something, something* Mayo Clinic *something, something* USA!
posted by Mental Wimp at 12:40 PM on June 18 [1 favorite]


Late to the thread but I am in the US with good insurance. I have a chronic back condition that long ago led to surgery, MRIs, and all sorts of other expensive stuff. A couple of years ago I got where I can manage it OK using stretching, swimming, and a 2x/day mild opiate pain medication. I go to a pain clinic for the meds, which of course are on various lists of possibly abused meds and so have strict prescription rules. I have to go in every 2 months to verify that my back still hurts and occasionally take a random drug test. No problem I guess ... but check this out:

- the meds are $50 a month co-pay (not *too* bad)
- the clinic is in a hospital so instead of my $40 co-pay I get charged a % till I meet my deductible, so the first couple of visits a year cost me several hundred dollars each.
- last time I got given a urine test (which isn't even medically needed - just to look for abuse of drugs), my part of the fee was something like $200.
- I get 2 bills, one from the hospital and one from the anesthesiologist group that owns the clicnic

My visits literally consist of an LPN saying "Does your back still hurt? Ok here's your refill prescription". My total outlay per year is something like $600 for the meds and maybe $1500 in visits (that's my deductible per year).

Frankly I say burn the system down and too bad if some profits are lost. Also there needs to be a "one visit, one bill" law. The clinic can then employ a billing person to pay whatever % goes to the hospital. I mean, what's next, I buy coffee and later I get 2 bills for "barista fee" and "cup charge"? Stupid. Indefensible.
posted by freecellwizard at 3:16 PM on June 18 [2 favorites]


Honestly, I don't get this "You can see a doctor any time you want!" in the US. In Asheville, at least, that is so not true it's laughable. You can go to an urgent care center - as I did today - but if you don't already have a regular doctor, good luck getting one to see you if you're sick. You need to find one who both takes your special insurance AND is accepting new patients, damn near impossible, and then you have to make an appointment that will usually be two to four months in the future for a baseline checkup and to see if you even like this doctor and whether, I guess, they will deign to take you as a patient. I wish I had jumped through these hoops when I first got insurance again last year because as it is when I finally and inevitably got first injured and then really sick, I ended up at an ER and an urgent care center. The ER visit is costing me $250 - almost a week's salary - and the urgent care center cost $50 and I'm not even going to go into the after insurance dentist bills, the out of network specialist bone and joint doctor bills that are piling up (pity he's out of network, his practice is the ONLY ONE in town, so what was I supposed to do with my torn rotator cuff, exactly?) or the truly outrageous bill that I got for a doctor's visit a year ago when I thought I had Medicaid. I did have Medicaid, but I had the ACA mandated well woman medicaid ONLY, which allows you to have one checkup per year only, and if that checkup finds something that needs, well, checking on, it is not paid for.

This morning at the urgent care (as we like to say, Sisters of Mercy, not sisters, not merciful, discuss!) I watched several women who thought they had medicaid get turned away at the billing desk. They don't let you into that clinic until you've paid so everybody gets to watch and hear. One lady needed a medicaid referral and there was only an answering machine at her regular doctor's office, or something, so she was on the phone calling a million numbers, begging to be allowed to see this doctor today while the billing clerks kind of snickered. The other lady had the same medicaid I used to, that only pays for checkups, nothing else, and if you're sick too bad. She had foolishly thought that that card meant she could go to the doctor if she got sick. North Koch-olina didn't expand Medicaid, you see, and the majority of my friends who tried to get Obamacare had to give up because of the prices. Nothing much has changed, here. Not affordable, not care and not really an action, yeah.
posted by mygothlaundry at 7:15 PM on June 18 [2 favorites]


My suspicion is that quality of care and cost measures are going to significantly lag behind after implementation of the ACA.

Yeah... Just wait... It gets better. We're really good at that, aren't we? Some of the best trained doctors in the world, and that's what it comes to.

Off to read the abortion thread now. Gonna get better real soon now.
posted by formless at 5:07 PM on June 20


Republicans Finally Admit Why They Really Hate Obamacare
posted by homunculus at 11:31 PM on June 25


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