Spending, Use of Services, Prices, and Health in 13 Countries
February 19, 2016 11:30 AM   Subscribe

 
The caveat here is that in some of these countries there's a fixed centralized control of medical spending. In Canada for instance they pretty much set the Medicare budget at the top (federal for subsidy payments, provincially for actual budgets) and then it flows down from there. So in a sense the notion of measuring Canada's medical spending growth rate is a non-measurement as it's more-or-less set by fiat.
posted by GuyZero at 11:46 AM on February 19, 2016


Health care in the US is a strange strange beast.

I really wish they would have included statistics on how much is spent privately plus public expenses for residents. It would make the GPD spending on healthcare even more out of proportion.
posted by AlexiaSky at 12:02 PM on February 19, 2016 [1 favorite]


So in a sense the notion of measuring Canada's medical spending growth rate is a non-measurement as it's more-or-less set by fiat.

Okay, but Canada is pretty much in the middle of the pack. Remove it from the presentation and the US is still the only outlier.
posted by Foosnark at 12:05 PM on February 19, 2016


yeah, definitely, it doesn't really change the argument much at all. I'm just sayin'.
posted by GuyZero at 12:06 PM on February 19, 2016


But isn't that part of the point? Other countries actually have mechanisms in place to keep costs down and still manage to achieve better outcomes. In the US the costs just seem to spiral farther and farther out of control.
posted by any portmanteau in a storm at 12:09 PM on February 19, 2016 [24 favorites]


The American argument against cost controls pretty much boils down to "death panels!!" which is both ridiculous and somewhat true. Someone is going to get denied care for a reason that's not "I can't pay."

Not very American.
posted by GuyZero at 12:23 PM on February 19, 2016 [1 favorite]


Healing America is an excellent book on this very subject. It was written in 2010, pre-ACA, but is still very much relevant. I really strongly recommend it. If not, I'll give you the theme of the book: "All developed-nation healthcare models suck, it's just that USA's sucks the worst."
posted by mcstayinskool at 12:26 PM on February 19, 2016 [1 favorite]


The caveat here is that in some of these countries there's a fixed centralized control of medical spending. In Canada for instance they pretty much set the Medicare budget at the top (federal for subsidy payments, provincially for actual budgets) and then it flows down from there. So in a sense the notion of measuring Canada's medical spending growth rate is a non-measurement as it's more-or-less set by fiat.

That's not exactly true. I mean yes the province makes budgets and based on those budgets things happen, but it goes the other way, too. The provinces know that they're required by the Canada Health Act to pay for all necessary care. So there's a lot of stuff they have no choice but to include in the budget. They know there will be on average X number of people with cancer and Y people with heart disease and it costs $W per year to treat cancer, on average, and $Z per year to treat heart disease. The cost of healthcare drives the budget number as much as the other way around. Further, it's not like they just stop spending money once the budget number is hit. If somehow they've budgeted a certain amount for blood test at private labs and the money runs out in October, they don't stop covering blood tests, they go overbudget.

Someone is going to get denied care for a reason that's not "I can't pay."

What are you talking about? Who is denied care for a reason that's not "I can't pay?"
posted by If only I had a penguin... at 12:30 PM on February 19, 2016


The thing that blows my mind is that Canada spends substantially less public money per capita than the US, while delivering better outcomes.

This is what drives me crazy about the debate about how much Bernie Sander's proposals for a Canadian-style, Medicare-for-all single payer system will cost. If it's anything like the Canadian system, total public spending will go down, not up.
posted by [expletive deleted] at 12:32 PM on February 19, 2016 [17 favorites]


siderea (who did that essay on class that was on the Blue recently) also has a (yet unfinished, which is why I haven't done a FPP on it yet) series of essays on health care costs in the US that I found very interesting in explaining why we're paying more and getting less in the US due to the way our system is set up:

Massless Ropes, Frictionless Pulleys: Coordinative Communication
A Hypothesis, Part 1: The Ineluctable Smell of Beer
A Hypothesis, Part 2: Two Things Happened
A Hypothesis, Part 3: Money Flows Through It
A Hypothesis, Part 4: The Proliferation of Organizations
A Hypothesis, Part 5: The Proliferation of Industries
posted by foxfirefey at 12:34 PM on February 19, 2016 [5 favorites]


The US essentially has two healthcare tracks - one for the insured that delivers better than average care at a terrible value for price, and a second track that is terrible health care for the uninsured. So when you staple them together you get this. But you can't really solve the first problem. People are pretty inelastic when it comes to health care so the case of "get care 95% as good for 65% of the price" isn't getting you anywhere. And obviously the electorate pretty much loves to fuck the poor so problem two is intractable.
posted by JPD at 12:42 PM on February 19, 2016 [5 favorites]




The thing that blows my mind is that Canada spends substantially less public money per capita than the US, while delivering better outcomes.



How are those outcomes measured? What is or is not controlled for?

Life expectancy is usually bandied about as proof that our health care system is broken compared to other OECD countries. But it turns out that the truth is a bit more complicated
posted by vorpal bunny at 12:44 PM on February 19, 2016 [1 favorite]


AlexiaSky: I really wish they would have included statistics on how much is spent privately plus public expenses for residents.

Page 2 of this OECD document breaks health spending down by public vs. private. Public spending is basically the same as Canada, about 8% of GDP. But the US spends another 8% on private health, while Canada spends another 2% or so on private health.

However, don't be too quick to laud Canada; we've done a decent job of getting immigrants into the health system, but Aboriginal health outcomes are, to put it mildly, not good. Given the vitriol that comes out whenever something like Idle No More gets going, it'll be a while before we are politically ready to actually equalize health outcomes.
posted by clawsoon at 12:48 PM on February 19, 2016 [3 favorites]


People are pretty inelastic when it comes to health care so the case of "get care 95% as good for 65% of the price" isn't getting you anywhere.

Or, y'know, how about "get 100% as good for 65% of the price"? Because that is an option, once you opt to not place corporate profits, high executive pay, inflated drug prices, inflated device costs, etc. etc. ahead of the health of your citizens.
posted by Thorzdad at 12:56 PM on February 19, 2016 [14 favorites]


vorpal bunny: But it turns out that the truth is a bit more complicated

From your link: "What happens if you remove deaths from fatal injuries from the life expectancy tables? Among the 29 members of the OECD, the U.S. vaults from 19th place to…you guessed it…first."

That leads me to ask: Is this because there's a much higher incidence of fatal injury in the US, or because emergency room treatment is that much worse? In either case, who are these injury deaths mostly happening to: The poor or the well-off? And why?

Is it occupational? Interpersonal conflict? Car accidents?

We know that the US is great a directing money toward the health of well-off older people, and the discussions leading from your link emphasizes that: The US is quite good at finding and curing cancer. However, it's horrible - for what reason? - at preventing and treating injuries for a large number of people. That's the major public health issue that needs to be solved in the US, by the sounds of it.
posted by clawsoon at 12:58 PM on February 19, 2016 [3 favorites]


If it's anything like the Canadian system, total public spending will go down, not up.

There are Devils in those details. Notice Canada has lower rates per capita for diagnostic scanners, MRIs and the like. Months-Long waits for non critical conditions and odd hours appointments (like 10 pm) are not uncommon.

On the other hand, we get better deals on many drugs than even the largest hmos seem to in the US.
posted by bonehead at 1:06 PM on February 19, 2016 [1 favorite]


This is what drives me crazy about the debate about how much Bernie Sander's proposals for a Canadian-style, Medicare-for-all single payer system will cost.

Well, just as having a larger military than the rest of the world put together creates all sorts of jobs for all sorts of people, having the developed world's most inefficient healthcare non-system keeps a lot of billing-code-looker-uppers and paper-pushers and kneejerk-claim-deniers and clipboard manufacturers in work.

But it turns out that the truth is a bit more complicated

So if Americans weren't shooting one another and having horrific fatal car accidents, they'd do a lot better on the life expectancy stats? I'm not sure what that's supposed to prove, but I'm sure as heck not going to seek enlightenment from Tyler Cowen, a man paid to flap his hands and defend the glorious free market from the comfort of a non-profit Koch-endowed think tank.

I'll second the value of TR Reid's book. As he noted, this is never going to be a solved problem, but it's a largely-solved one with different solutions across the developed world other than the US. What those solutions have in common is direct political accountability for failures in the healthcare system, whether it's public or private provision. The only time the US has seen that kind of accountability in recent years has been over Walter Reed and the VA: the executives who run hospital groups or insurance companies aren't accountable to the people who use them; the politicians who vote against Medicaid expansion are apparently beyond accountablity to the people they fuck over.
posted by holgate at 1:07 PM on February 19, 2016 [10 favorites]


Our horribly low infant mortality rate is seemingly correlated to socio-economic status. We take great care of babies in the hospital, but not after they get home.
posted by RobotVoodooPower at 1:08 PM on February 19, 2016


Notice Canada has lower rates per capita for diagnostic scanners, MRIs and the like. Months-Long waits for non critical conditions and odd hours appointments (like 10 pm) are not uncommon.

Depending on how "non critical" is defined, I think I'm okay with that. It sure would beat our long waits for healthcare in the US: waiting until either you can save up or get a good credit card to pay for a procedure, and/or waiting months to see if you're going to make your deductible, then shooting the moon on a $$$$ MRI bill. After that, you just hoping you can cram in the necessary care before your insurance year ends and you're back to zero on the deductible.

And I will gladly go for a 10:00 doctor's appointment if it means the financials aren't as miserable.
posted by witchen at 1:10 PM on February 19, 2016 [7 favorites]


The US is good at critical care. What happens at home and resources to manage and prevent things like diabetes is so so lacking.

Poor and need to moniter glucose? Self pay.

I cannot tell you the number of people who forgo maintenance medication due to Co pays.
posted by AlexiaSky at 1:15 PM on February 19, 2016 [4 favorites]


Who is denied care for a reason that's not "I can't pay?"

Well, in the UK, we have an august body called NICE. If it thinks that treatment X is not A Good Idea on the grounds of clinical outcome and, yes, cost, then you can't get treatment X through the National Health Service. If you have decided that treatment X is the only treatment for you then you might say you are "denied care". (Maybe you've seen some advertising from the pharmaceutical company that has developed X, perhaps... though that is illegal in the UK - no 1st Amendment here!)

What happens if NICE ... does not recommend the treatment?
posted by alasdair at 1:25 PM on February 19, 2016 [2 favorites]


The US is good at critical care. What happens at home and resources to manage and prevent things like diabetes is so so lacking.

Poor and need to moniter glucose? Self pay.

I cannot tell you the number of people who forgo maintenance medication due to Co pays.


And that is where having someone responsible for the whole system makes a difference. They can look at the figures and say we are paying X in the emergency room due to complications from diabetes. If we gave everyone access to insulin pumps it would cost Y and reduce X by some fraction (because there will still be people going to the emergency room for complications, just not as many). If the numbers make sense then you give everyone insulin pumps.

Dental care isn't covered by the public health system in Canada. There was a call-in show on CBC Radio 1 maybe a month ago where they were discussing whether it should be. And one of the proponents basically gave a calculation like that. As in "we are already paying X in the emergency room due to untreated dental issues, if we put that money into providing basic dental care we'd be paying the same but getting better outcomes".
posted by any portmanteau in a storm at 1:27 PM on February 19, 2016 [5 favorites]


About the death panels: The Cost of End-of-Life Care It's a random googled article, but covers the issues well. Because I've lost several family members to cancer during the last decade, I've been obsessing about this discussion, which exists across the globe. A huge chunk of the money we spend on health-care goes into the last two months of life, after everyone knows you are dying and cannot be saved. And that medicine and "care" will make your last days miserable. Atul Gawande has been writing about this
Obviously, I believe that we should use every last resort when there is even the smallest chance of saving someone with a fatal illness. But at some point there is no last resort, and what you need to do is to come to terms with death, and you need the relevant care for that. Because it is the human thing to do.
Hospitals don't work that way, and they probably shouldn't: they are huge machines for saving lives, and everything needs to be geared for that purpose. But that also means that resources are used in ways that are not the best care for the patients and which are also immensely expensive.
After my experience I know I want to die at home or in a hospice, and I will refuse life-prolonging therapy if I know there is no chance of saving my life. This will save society millions. But that is not the reason for my choice. I don't want to die in pain, in a hospital. I've seen how that works, and I will do everything in my power to avoid it.
I've specifically seen people who had the money and power to get hospitals to struggle till the very last minute to save their lives, and this option is a huge element in the lore of freedom and choice in health-care. I can tell you that those last days are the worst I have experienced and I would not wish them for my most evil enemies.
posted by mumimor at 1:41 PM on February 19, 2016 [5 favorites]


I cannot tell you the number of people who forgo maintenance medication due to Co pays.

Here's American healthcare in all of its disjointed glory: elderly Medicare recipients get prescribed more glucose test strips than they need because Medicare's inviolable; they sell their excess on the grey market to make a little extra money, and those strips are bought off eBay by T1 diabetic adults who are either uninsured, underinsured, or whose expensive insurance policies limit the number of test strips you can be prescribed... perhaps because they feel any excess will be sold on the grey market.

Diabetes support groups are typically swap meets for meds and supplies: someone may have struck it lucky with a pharma or device rep while someone else has had a cashflow crisis or inadvertently had their insulin go bad. That this happens is ridiculous and scandalous.
posted by holgate at 2:03 PM on February 19, 2016 [11 favorites]


Glucose strips for Type I diabetics are a bit disjointed in Canada, too. If you're poor, you can apply for special programs to pay for them. If you're not, you have to either pay out of pocket or have private/work insurance. This is true in Alberta and Ontario, anyway.
posted by clawsoon at 2:10 PM on February 19, 2016


But lest anyone think I'm bashing the health system of my home country: My daughter spent two weeks in the NICU when I was without a job and had no private insurance. What would the bill for that have been in the US? Would I have faced bankruptcy?
posted by clawsoon at 2:12 PM on February 19, 2016 [3 favorites]


vorpal bunny: Life expectancy is usually bandied about as proof that our health care system is broken compared to other OECD countries. But it turns out that the truth is a bit more complicated

Did you even read the comments to that blog post? They tear that study to shreds. Note this excellent comment by Barkley Rosser (JMU economist):

I am going to hammer this worthless study one last time. There is reason to believe that they in fact structured it to make a propagandistic point and overstate the supposed effectiveness of the US health care system.

A highlight is the cancer survival rate chart, where the US is tops. Indeed, the US health care system is excellent in certain areas, with cancer being the most important. The US is tops overall. However, the second best performer is France. Look at that table. France is not on there. Why is that? Well, leaving France off sure makes the US look even more spectacularly good than it is. Did the authors consciously leave France off to make such an exaggerated appearance? I do not know. But, I do not think they are stupid.

posted by crazy with stars at 2:13 PM on February 19, 2016 [8 favorites]


Here's a half-baked thought: Do Americans spend more on healthcare simply because healthcare services are heavily advertised in the US?

In countries with single-payer systems, there's very little "come to our hospital because it's great!" advertising. I'm always surprised when I see those ads on American TV. Maybe high healthcare spending in the US is simply a result of the fact that advertising works?
posted by clawsoon at 2:31 PM on February 19, 2016


But lest anyone think I'm bashing the health system of my home country: My daughter spent two weeks in the NICU when I was without a job and had no private insurance. What would the bill for that have been in the US? Would I have faced bankruptcy?

If your social/support network is strong and vocal, you may have been able to crowdfund it. Either from a site like youcaring dot com or in a jar at the register at your local diner. Otherwise, unless you had extensive savings and/or family help, it would put an "average" (middle-class) adult into six figures of debt.
posted by witchen at 2:36 PM on February 19, 2016 [2 favorites]


As a good example of how you can have good coverage and low spending WITHOUT single-payer, look at Japan here. Great health outcomes, low spending per person ($3713 is one of the lowest in that chart), even with high medical usage (high MRI / hospital utilization, etc) and the highest number of physician visits per year.

How? Regulation and cost control.
posted by thefoxgod at 2:51 PM on February 19, 2016 [3 favorites]


Well, in the UK, we have an august body called NICE. If it thinks that treatment X is not A Good Idea on the grounds of clinical outcome and, yes, cost, then you can't get treatment X through the National Health Service. If you have decided that treatment X is the only treatment for you then you might say you are "denied care".

I had no idea. There's nothing like that here. I wonder if this would go away if the UK had a single payer system? There used to be a single-payer system there, right? Did it exist then? My hypothesis is that this is a lot less likely to be tolerated under a single payer system since the well-off people used to getting their way can't just buy the treatment privately, so they won't tolerate being denied in the public system.

And yeah, on life expectancy, I have no idea why a accidental deaths shouldn't be attributed to the US healthcare system and public-health system.
posted by If only I had a penguin... at 3:03 PM on February 19, 2016


clawsoon, yeah, bankruptcy.

And someone mentioned waiting for MRIs and getting odd-hour appointments. I live in the USA and have what would be considered decent insurance here. And I happen to have had an MRI just this week.

It was scheduled for 9pm. When I arrived, everything I passed on my way into the bowels of the hospital was closed. But the MRI clinic was busy. I was curious so I asked the MRI tech. He said this hospital has six MRI machines and they run them 24/7. My late night appointment was during this guy's normal shift.

(I have had MRIs that started as late as 2am and there are always people after me. One time I had an MRI in a truck, Ishityounot. That hospital had a portable MRI that went to different hospitals and moved every couple days. The hospital had a special bay for the truck to back into and operate the MRI there.)

This recent MRI was prescribed four months ago, but I put it off until this week because of concerns about how I'd pay for it. The folks at the hospital claim I can expect to pay about $2000 out of pocket. This is because I have another $500 to go on my deductible, and after that a ten percent copay. So doing the math it seems this little adventure is gonna cost the insurance company, what, thirteen or fourteen thousand dollars?

And all of that is assuming the person on the phone at the hospital even has a clue what it costs. My experience with how well they predict the costs of anything, has not been good. Also, you don't even know when you are finished paying, because they split everything out a la carte and charge it separately, and all those little departments bill at different speeds. So that prediction they gave me may include the time on the machine, but not the rest of the things. Maybe I'll get that $2000 bill in April, and in May I'll get a bill for the dye they put in my arm, and in June a bill for the radiologist who reads the darn thing, and in July a bill for something I can't even figure out what it is. And if you contact the billing department and ask "Is this the last bill yet?" they will reply "You currently owe $253.16." and I'm like, that wasn't my question, but really if you hound them it's useless because they have no idea if/when another bill is going to trickle out. She's just some poor shmuck who has a job almost as horrible as being a telemarketer.

I was ranting about this to some friends and one of my friends whose wife died, told me that he was billed thousands of dollars for tests that were ordered for his wife, on the day she died. The lab work was performed the day after she died, and insurance ends at death, so they were not covered. :(
posted by elizilla at 3:14 PM on February 19, 2016 [18 favorites]


So doing the math it seems this little adventure is gonna cost the insurance company, what, thirteen or fourteen thousand dollars?

Which is kind of incredible. An hour of fMRI time at a research uni in the UK is billed at about 300-500 quid including an operator, onsite tech and estates costs.
posted by srboisvert at 3:17 PM on February 19, 2016 [4 favorites]


I was ranting about this to some friends and one of my friends whose wife died, told me that he was billed thousands of dollars for tests that were ordered for his wife, on the day she died. The lab work was performed the day after she died, and insurance ends at death, so they were not covered. :(

I would think that one's legal ability to incur debt also ends at death.
posted by If only I had a penguin... at 3:17 PM on February 19, 2016


Who is denied care for a reason that's not "I can't pay?"

Well, in some parts of the US, people seeking care that runs counter to Catholic teachings, for starters, and a lot of women in Texas and Wisconsin (and other states but there are too many previouslys to collect), as well.
posted by kristi at 3:25 PM on February 19, 2016 [6 favorites]


Which is kind of incredible. An hour of fMRI time at a research uni in the UK is billed at about 300-500 quid including an operator, onsite tech and estates costs.

Well, I was in there for a bit over two hours. But still!

You see all this stuff about how the copays are meant to reduce moral hazard, by making us more price-sensitive due to having "skin in the game". I find this notion infuriating, because how can we be budget-conscious when no one can even tell you what it will cost, no matter how carefully you question them? And when you question the doctor, asking if this MRI is really necessary, because hello, it's super expensive, they say stuff like "If you don't have insurance you should sign up with this or that charity organization, see if you qualify to have them pay for it."

It's not only that I don't want to pay for it myself. I also don't want to have the insurance company pay $14K! Or a charity either! Not if it's not truly necessary. So tell me if it's necessary. What are you going to do with these results? Anything??? And when I say this the doctor looks at me like I have three heads.

I would think that one's legal ability to incur debt also ends at death.

He didn't say he paid it. Just that they billed it.

I bet a lot of bills like that don't get repudiated. People think they have to pay this stuff. How many poor widows and widowers are eating cat food because they unquestioningly handed over all their remaining savings to pay what the insurance didn't cover for the post-death charges?
posted by elizilla at 3:47 PM on February 19, 2016 [7 favorites]


My brother was a premie and between my mothers start abs my Brothers (6 weeks between the two) the bill came in a three ring binder.
posted by AlexiaSky at 3:54 PM on February 19, 2016


Dental care isn't covered by the public health system in Canada.

Important to note: some of the strongest opposition to Medicare in Canada came from doctors and dentists themselves. The dentists won and the CMA isn't an innocent bystander.
posted by klanawa at 7:44 PM on February 19, 2016 [2 favorites]


The dentists won and the CMA isn't an innocent bystander.

The dentists won, to some extent, in the UK as well. The common thread among developed-nation healthcare is 'fuck the dentists, because they don't give enough of a fuck about you, and fuck the opticians too, but not as much as dentists'. Sorry, dentists, but you made a rod for your own back: there's a reason why Rachel in Friends jilts Barry The Dentist, because Barry is an arse, and Barry is a dentist.
posted by holgate at 8:14 PM on February 19, 2016


Just the other day there was a flurry of attention to a study that showed that in the US richer people are living much longer, while poor people are dying earlier. When I look at the charts in this article, that is what I think of -- the very real outcomes of our inequitable system. I'm just high enough on the spectrum to be doing ok with the current system (with decent but not amazing insurance, and enough income to pay deductibles and random charges), but it's still such an obviously shitty system that I would love to tear it down and start over.
posted by Dip Flash at 8:44 PM on February 19, 2016 [2 favorites]


Dental care isn't covered by the public health system in Canada.

It's not mentioned very much but neither are a lot of prescriptions and extras.

When I had my appendix removed under OHIP (Ontario's heath insurance) my parent's company provided extra insurance had to cover my anesthesia, pain meds, hospital room fees and food.
posted by srboisvert at 3:47 AM on February 20, 2016 [1 favorite]


Well, in the UK, we have an august body called NICE. If it thinks that treatment X is not A Good Idea on the grounds of clinical outcome and, yes, cost, then you can't get treatment X through the National Health Service. If you have decided that treatment X is the only treatment for you then you might say you are "denied care".

In the US, the insurance companies follow this same process, only it is much more arbitrary because each insurance company has a different set of rules, they change the rules on a whim and are under no obligation to tell their customers when they have changed the rules, and their appeals boards are "medical professionals" with no expertise in the specialties on which they are making decisions.

I recently had the fun of having to argue that the drug that had literally made it possible for me to go back to work and not be disabled, a drug that I had been taking for 5 years, was medically necessary because the insurance company that I had been involuntarily switched to for prescription coverage suddenly decided after I was their customer for 6 months that this drug needed prior approval even though it was not (and is still not) on their prior approval list.

I'd rather go with a single government panel whose decision making wasn't biased by the need to give their CEO big bonuses.
posted by hydropsyche at 4:53 AM on February 20, 2016 [6 favorites]


Srboisvert, that's awful. I was going to ask what province you were in, but I see you say Ontario, so there's probably some clarification in order. Ontario has always covered drugs administered in hospital, do it must have been pain meds after you sent home that your private insurance covered. Similarly, hospital room fees are covered, but if you request a private or semi-private room, there are extra fees for that. Had you not made that request, (and I suspect any acknowledgement that your insurance covers it is taken as a request), there would have been no room fees. Basically, a room upgrade for non-medical reasons is considered a non-medical perk, so there's no reason for medical insurance to cover it. I wonder if there was also some kind of similar food upgrade.

I think you must be mistaken about anesthesia. Anesthesia is covered and its illegal for you or your insurance company to pay for covered services.

I've had lots of inpatient treatment in Ontario in my life and so havey family members. We've never been charged for rooms, food, drugs or anesthesia. It's all covered. And this wouldn't be a different hospitals do things differently thing because it is illegal for the hospital to hill an OHIP-insured person for OHIP-covered services.
posted by If only I had a penguin... at 7:34 AM on February 20, 2016


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