Privatizing health care is not the answer: lessons from the United States

Marcia Angell

doi:10.1503/cmaj.081177

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A balanced view...
Nisar M Huq

Posted on: 28 November 2008
Thank you Dr. Angell!
Brian C Dixon-Warren

Posted on: 13 November 2008
Privatizing Health Care in Canada
David M. Pelz

Posted on: 03 November 2008
the evils of privatization
andrew stapleton

Posted on: 30 October 2008
comparative observations about healthcare systems un the USA and Canada
Lois E Klein

Posted on: 23 October 2008
What about the rest of the Western world?
Charles T. Low

Posted on: 21 October 2008
Don't Let Privatization Hijack Our Physicians
Shaheen E Lakhan

Posted on: 14 October 2008
Better than America is not enough
Wesley D Block

Posted on: 10 October 2008

Posted on: (28 November 2008)
Page navigation anchor for A balanced view...
A balanced view...
Nisar M Huq
Dear Dr. Angell,
I read with great interest your article on the comparison of the Canadian and American Health Care systems. It was well researched and topical for certain. As a Canadian physician that has practiced in both countries in private and academic settings and I continue to practice, and as someone that has numerous family members of different generations practicing in both countries there are some p...
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Dear Dr. Angell,
I read with great interest your article on the comparison of the Canadian and American Health Care systems. It was well researched and topical for certain. As a Canadian physician that has practiced in both countries in private and academic settings and I continue to practice, and as someone that has numerous family members of different generations practicing in both countries there are some points I thought worth raising.
When you report that ‘37% of Americans reported that they went without needed care because of cost, compared to 12%’ it doesn’t really address what is perceived as ‘need’. It could be that individuals in either country have a different expectation of need. Also when ‘cost’ is quoted it seems to ignore the personal responsibility. I have patients that refuse to pay even 20$ a month to me but I literally see them with expensive clothes like 400$ boots and actually saw one patient buying a 600$ video game system at wall mart!
In fact everyone in America doesn’t want health insurance…this effort was vigorously fought when suggested. Almost half of all uninsured have incomes that are more than twice the poverty levels and 20% have incomes in excess of 100, 000$ per year!
So in framing any discussion it is important for us to separate out ‘poor’ and ‘uninsured’.
As a physician practicing in the US I would also say that there is an idea that the uninsured don’t get care; this isn’t true. There are many federal programs and routinely when we are on call we take many patients from the emergency room that have no insurance.
I think it is important to look at ethical underpinnings of a system. From a teleological moral duty, where the outcome is what is important, than the US system fits its social world view. On a practical level Americans do want to be able to have healthcare how and when they choose and feel that there is some personal responsibility. In a land where hard work and capitalism are rewarded it is felt that the result is what counts.
Under the Canadian social system or a deontological ethical framework it is the idea that everyone should have coverage that is important. This is derived from Kantian ethics and is distinguished from a utilitarian standpoint. So it is immaterial whether someone has to wait for an MRI for a life threatening cancer or for a hip surgery. As long as everyone is covered with the same blanket then their system is defensible based on the fundamental ethical underpinnings.
Some suggestions I would make is for there to be donations from pharmaceutical companies, hospitals and doctors to help uninsured people that want and need help.
This has been very successful in communities in the US.
For Canada simply allowing physicians and hospitals to charge separately for services would alleviate some of the ‘waiting’ line criticism. The system in England is similar to this where there is a private and public component. This would allow everyone to get a basic level of care but also allow those patients that felt they would like to pay privately for their health care an avenue that is separate from their existing one of coming to the US for treatment.
The other real issue is whether in fact there is any need to change either system.
One could argue that Canadians get a basic level of health care and if they want to ‘jump the line’ awaiting a hip replacement in Windsor Ont they can drive 5 minutes to Detroit Mi and pay for it. From an American standpoint and looking at what is referred to ‘revealed preference’ those insured are really not willing to pay very much to solve the perceived problem of the ‘uninsured’. In a country that was founded on self- reliance and independence these sentiments are not hard to understand.
My final comment is that when we actually look at the social and cultural framework of both countries maybe the health care systems are actually ‘evolved’ already to what each population desires?
Just my thoughts.
Thank you for your indulgence.
Sincerely,
N M Huq, MD, FRCPC, FACC, MBA
ABIM certified General Internal Medicine, Cardiology, Interventional Cardiology
CBNC certified Nuclear Cardiology
Reference: 1 Herrick Devon M, Five Myths about the Uninsured in America, National Center for Policy Analysis retrieved Nov 21, 2009 from http://www.ncpa.org/ba/ba339/ba339.html
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (13 November 2008)
Page navigation anchor for Thank you Dr. Angell!
Thank you Dr. Angell!
Brian C Dixon-Warren
Thank you for a very timely important statement. Your status as past Editor of the New England Journal of Medicine guarantees that it will be heard. The timing is especially important in view of the recent tilt to the right of governments with regard to medical care. This is true both in Ottawa, & in Victoria (in my own province). There are only two caveats, that need to be discussed before they are raised by the proponents...
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Thank you for a very timely important statement. Your status as past Editor of the New England Journal of Medicine guarantees that it will be heard. The timing is especially important in view of the recent tilt to the right of governments with regard to medical care. This is true both in Ottawa, & in Victoria (in my own province). There are only two caveats, that need to be discussed before they are raised by the proponents of private health care. 1) The issue of personal freedom needs to be addressed. There is a strong argument that patients have the right to spend their disposable income as they choose. Physicians have the right to choose the financial arrangements in their practice. Clearly private-pay must not be allowed to undermine the public system. However, I believe that there is only a small minority of patients who could afford to pay privately. Consequently, there will only be a small number of physicians who will be able to support themselves in true private practice. Thus, this may well be a stable self-regulating & acceptable arrangement. This needs to be researched. 2) I am concerned that the comparison of two very different systems may not be entirely valid. In the recent past the USA has been a much more wealth country than Canada, & of course has a hugely larger population. These differences may make it difficult to make direct comparisons. In Canada we have never had a definition of "medically necessary care". When I was a medical student, & young doctor in the '50s & the 60s the physician implicitly set the definition. With the welcome coming of Medicare the definition was increasingly set by the paying agency in negotiation with organized medicine. 3rd party payment for fee for service increasingly became, at least in General Practice, a fixed fee per encounter. Later still, as patient autonomy became increasingly accepted the definition is tending to be set by the patient. Hence the lobbying for public funding of alternative medicine etc. My own opinion is that the current so-called fee for service system is broken, & should be largely discarded. In General Practice the capitation system has much to recommend it, with individual fee payments for specific items only. Again, thank you Dr. Angell; & thank you CMAJ! Brian Dixon-Warren.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (3 November 2008)
Page navigation anchor for Privatizing Health Care in Canada
Privatizing Health Care in Canada
David M. Pelz
As an MD who has practiced in the beleaguered Canadian health care system for over 30 years (and who is old enough to have used the first edition Dr. Angell's Pathology textbook in medical school!), this critique of the US health care system comes as a breath of fresh air. Although our system creaks along and waiting lists seem to be never-ending, it is easy to lose sight of the positive features so eloquently pointed out...
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As an MD who has practiced in the beleaguered Canadian health care system for over 30 years (and who is old enough to have used the first edition Dr. Angell's Pathology textbook in medical school!), this critique of the US health care system comes as a breath of fresh air. Although our system creaks along and waiting lists seem to be never-ending, it is easy to lose sight of the positive features so eloquently pointed out in this article. It should be required reading for medical students to help them resist the "siren song" of high remuneration in the US, and to remind them that medicine is not primarily a business.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (30 October 2008)
Page navigation anchor for the evils of privatization
the evils of privatization
andrew stapleton
I am confused. Dr Angell first states that "46 million Americans without health insurance might wait for the rest of their lives" for hip replacements, but two paragraphs later says that "waiting times for hip replacements in the US are short because most hip replacements are done in the public system for elderly patients." My recent encounter with our system involved a sports injury where I was advised to get an MRI. Wh...
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I am confused. Dr Angell first states that "46 million Americans without health insurance might wait for the rest of their lives" for hip replacements, but two paragraphs later says that "waiting times for hip replacements in the US are short because most hip replacements are done in the public system for elderly patients." My recent encounter with our system involved a sports injury where I was advised to get an MRI. When my physician faxed off the requisition to the local hospital where I have been on staff for 33 years I waited a week before I received news that I could be accommodated in four months time. A simple phone call to the evil empire south of the border got me a convenient appointment 2 days later. In Canada I can spend my money freely on booze smokes and government run gambling, or on a myriad of useless alternative health care options, but for the greater good of the state never on a simple medical test delivered in a timely fashion. It seems ludicrous that this service could not be offered in own country. Andrew Stapleton MD
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Competing Interests: None declared.
Posted on: (23 October 2008)
Page navigation anchor for comparative observations about healthcare systems un the USA and Canada
comparative observations about healthcare systems un the USA and Canada
Lois E Klein
Before leaving Canada to spend a year in San Francisco (meeting my husband expanded that time to 47 years), I was privileged to work as a Public Health Nurse in Windsor, Ontario in 1962. The first healthcare program, "Windsor Medical" began there, started by seven physicians with altruistic intentions, and was lauded by the community. $17 came out of my paycheck twice monthly for my care, and I didn't miss it even thoug...
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Before leaving Canada to spend a year in San Francisco (meeting my husband expanded that time to 47 years), I was privileged to work as a Public Health Nurse in Windsor, Ontario in 1962. The first healthcare program, "Windsor Medical" began there, started by seven physicians with altruistic intentions, and was lauded by the community. $17 came out of my paycheck twice monthly for my care, and I didn't miss it even though I earned less than $400/month overseeing the 4 schools in the rural community with 5,000 families where I saw all those discharged from hospital within a week, and parturients within 3 days of discharge.
What I have seen in the USA of their attitude toward public healthcare programs frightens me. Most people compare it to "socialism" (as the Saskatchewaners did), knocking it out of possibility at the outset. Doctors have been "spoiled" by their ridiculously high incomes, (my obstetrician earned $800,000in 1973, and during my visits to his office complained constantly to me about the cost of his malpractise insurance - $100,000. and their super luxurious surroundings, thinking they deserve seven figure annual incomes, expensive cars and homes, etc. Their educational preparation lacks heart, and TV programs support disregard for consideration of patients' needs (think "House").
When I saw the ophthalmologist in Toronto during my visit there a week ago, I was impressed first by his use of equipment, the exposed wires in the ceiling of his examining room, and small waiting room. His care and explanations to me were superb!
I tell Americans that "single party payer" will reduce decor of medical facilities, but produce doctors who care more for practising medicine.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (21 October 2008)
Page navigation anchor for What about the rest of the Western world?
What about the rest of the Western world?
Charles T. Low
Fascinating reading, but Dr. Angell's reading makes no mention of the rest of the Westernized world. I have been led to believe that we in Canada are the only country with an almost 100% publicly-funded system (in many areas of care). Is that correct? If so, why? What do they do elsewhere and how well does it work? My colleagues around the coffee machine don't seem to know either, and we would all like to. Tell us about...
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Fascinating reading, but Dr. Angell's reading makes no mention of the rest of the Westernized world. I have been led to believe that we in Canada are the only country with an almost 100% publicly-funded system (in many areas of care). Is that correct? If so, why? What do they do elsewhere and how well does it work? My colleagues around the coffee machine don't seem to know either, and we would all like to. Tell us about Europe, for example. Comparing only Canada and the U.S. seems to be looking at only two ends of a very wide spectrum.
Dr. Angell also does not refer to political short-term interference in what so desperately needs to be long-term planning; this confounding variable has caused untold grief, suffering and loss of life in Canada, and continues to do so. How could a publicly-funded system avoid that?
It is noteworthy that Dr. Angell ends with "I believe it needs to be better funded from the public purse" and "the wisest course for Canada is to expand and reinforce the public system, not undermine it". As I remind bureaucrats at every opportunity, we Canadian health care providers are not asking for the most expensive system we can imagine; we are asking for the most appropriately-funded, and that almost axiomatically will not be the cheapest (which so often seems to be the actual goal).
Overall, I also support a vigorously-supported public health care system. I would like to paraphrase Dr. Angell's advice to the U.S.: "the only way ... is to change the system entirely." What directions that change might take could be an amazing and dynamic adventure as Canada continues - one hopes - to rethink and reshape the ways in which we deliver health care.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (14 October 2008)
Page navigation anchor for Don't Let Privatization Hijack Our Physicians
Don't Let Privatization Hijack Our Physicians
Shaheen E Lakhan
Dear Editor,
After reading the analysis by Dr. Angell, Privatizing healthcare is not the answer: lessons from the United States [1], I must agree. Completely changing the system of healthcare in Canada is imprudent and the current system is what is needed for patients of the country. The US insurance companies do a very good job of making money for themselves and this is their selfish nature. A health system sh...
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Dear Editor,
After reading the analysis by Dr. Angell, Privatizing healthcare is not the answer: lessons from the United States [1], I must agree. Completely changing the system of healthcare in Canada is imprudent and the current system is what is needed for patients of the country. The US insurance companies do a very good job of making money for themselves and this is their selfish nature. A health system should serve the people as a function of their inherent right to healthcare. Changing the system of healthcare would be expensive and any proposed spending should go towards fixing and maintaining the current healthcare system.
With one of the key problems being wait times, it was an excellent decision by the government to investigate this concern and guarantee a solution by 2010. Any spending should be focused on issues that can bring solutions sooner than later. In fact, like others that criticize privatization, we cannot afford to lose doctors and nurses who would be lured to more appealing private hospitals. This would further strain the public health system.
In the event that privatization does occur, the Canadian government cannot afford to allow lower income individuals to lose access to healthcare like the US system. The US Medicaid system is strong and takes care of the individuals at the bottom of the socioeconomic class but it does not grant coverage to the lower middle class who have low paying jobs or jobs that do not meet full-time criteria. Unless a system is created so that different packages at different affordable prices are offered, a system of privatized medicine will only create uninsured individuals who work hard but do not receive enough to pay out of pocket.
Americans are dealing with their own politics of healthcare in a time when their elections are using the issue of healthcare as a debatable topic to get the officials elected. However, their reality of changing from private healthcare to a public system will not come easy and they too should focus on fixing the system they currently have. Their system may look like its helping the majority and that might look appealing to Canada's healthcare, but you should not be distracted by a profit seeking system that does not keep the patients best interest in mind. Canadians simply cannot afford to create problems the American healthcare system brings along.
1. Angell M. Privatizing health care is not the answer: lessons from the United States. CMAJ 2008; 0: cmaj.081177v1
Conflict of Interest:
None declared
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Competing Interests: None declared.
Posted on: (10 October 2008)
Page navigation anchor for Better than America is not enough
Better than America is not enough
Wesley D Block
I would like to congratulate Dr. Angell on her well argued point that the Canadian health care system is superior to that of the USA with respect to the efficient delivery of services to its entire population (1). However, it is imperative that the USA not be the only standard to which we Canadians compare ourselves. Figures from the Organisation for Economic Co-operation and Development (OECD) indicate that Canada has a...
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I would like to congratulate Dr. Angell on her well argued point that the Canadian health care system is superior to that of the USA with respect to the efficient delivery of services to its entire population (1). However, it is imperative that the USA not be the only standard to which we Canadians compare ourselves. Figures from the Organisation for Economic Co-operation and Development (OECD) indicate that Canada has a mere 2.1 physicians per 1,000 people compared to the 3.8-4.0 physicians per 1,000 people in countries like Belgium, Switzerland and the Netherlands (2). In terms of practising nurses, Canada’s 8.8 nurses per 1,000 people pale in comparison to countries like Norway, Luxembourg, Ireland and Denmark that have between 15.3 and 31.6 nurses per 1,000 people (2). Despite all the attention politicians have paid to the issue of doctor shortages, the total number of first year students enrolled in Canadian medical school has increased by only 14% in the last 3 years from 2,380 students in 2005 to 2,711 students in 2008 (3,4). Perhaps Canada needs to focus beyond the USA when it looks for solutions to its health care challenges.
1. Angell, M. 2008. Privatizing health care is not the answer: lessons from the United States. CMAJ Early Release (October 6, 2008)
2.www.irdes.fr/EcoSante/DownLoad/OECDHealthData_FrequentlyRequestedData.xls
3.www.afmc.ca/pdf/pdf_2007_cmes_trend_first_year_undergraduate_enrolment.pdf
4.www.afmc.ca/pdf/2008_admissions_book.pdf
Conflict of Interest:
None declared
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Competing Interests: None declared.