• Phantoms in the snow

    Based on the comments I’ve seen over the last week, many of you are still going with that well used meme in the health care debate that people in other countries – frustrated by wait times and rationing – come to the United States for care.  These are almost always anecdotal stories and you should know by now how much stock I put in anecdotes.

    As always, when we can we should turn to evidence and research, and on this topic it does exist.  The most comprehensive work I’ve seen on this topic was published in a manuscript in the peer-reviewed journal Health Affairs.  That study looked at how Canadians cross the border for care.  Most anecdotes involve Canadians, since it’s easy for those on the border to come here.  And, the authors used a number of different methods to try and answer the question*:

    1) First, they surveyed United States border facilities in Michigan, New York, and Washington.  It makes sense that Canadians crossing the border for care would favor sites close by, right?  It turns out that about 80% of such facilities saw fewer than one Canadian per month.  About 40% saw none in the prior year.  And when looking at the reasons for visits, more than 80% were emergencies or urgent visits (ie tourists who had to go to the ER).  Only about 19% of those already few visits were for elective purposes.

    2) Next, they surveyed “America’s Best Hospitals”, because if Canadians were going to travel for care, they would be more likely to go to the most well-known and highest quality facilities, right?  Only one of the surveyed hospitals saw more than 60 Canadians in one year.  And, again, that included both emergencies and elective care.

    3) Finally, they examined data from the 18,000 Canadians who participated in the National Population Health Survey.  In the previous year, only 90 of those 18,000 Canadians had received care in the United States; only 20 of them had done so electively.

    Here’s another way to look at that final statement:

    Look, I’m not denying that some people with means might come to the United States for care.  If I needed a heart/lung transplant, there’s no place I’d rather be.  But for the vast, vast majority of people, that’s not happening.  You shouldn’t use the anecdote to describe things at a population level.  This study showed you three different methodologies, all with solid rationales behind them, all showing that this meme is mostly apocryphal.

    Maybe that’s why the manuscript was titled, “Phantoms in the Snow.”

    *Yes, periodically I may recycle something from my old blog, which many of you missed.

    • This one drives me nuts also. I trained at one of those hospitals. I remain affiliated with it. Seeing Canadians was always rare. Yet, even docs like to believe this myth.

      This also leaves out Canadians who cross the border to work here. A Canadian friend, a nurse, crosses the border to work outside of Detroit. For minor procedures, she and her family choose to go her hospital’s surgicenter since her friends work there.


    • As one of these Canadians you are talking about, I don’t understand your point.

      Just because the majority of us don’t travel to the USA for health care doesn’t mean we are content with our lot and the quality of care up here. I think it means most of us don’t have the money to finance out-of-country care or that we are willing to put up with the waiting lists and delays present in this country, except in extreme cases (like transplants or whatever).

      Also, private health care is mostly illegal in our country. If it were legalized and Canadians could pursue alternative domestic options for their health care, don’t you think we would? The fact that I can get a CAT scan for my cat immediately, but have to wait for myself is a case in point.

    • Tim: Right off the bat I’m just going to come out and say I doubt you’ve ever had to wait for a CAT scan in your life. They only take ~15-30 mins to complete and, in Bryan, TX, a regional hospital town serving a pop of maybe half a mil over hundreds of miles, there are maybe 20 people a day, at most, who need a CAT scan. Unless you lived in Toronto, and for some reason Toronto only has a single CAT scanner (which I know it is not the case) then there’s no way you’ve ever had to wait more than a few minutes to get a scan. Another thing you’ve never had to do? Look at a bill charging you $10,000 for that CAT scan because hospitals and private insurers game the system to drive up procedure costs.

      • My wife just waited for 6 weeks for a CAT scan after a vehicle roll-over. So while you may not believe it, it’s happening. Was it deemed “emergent?” No – but it was still pretty important.

        I have children who have waited for 8 months for surgical procedures, all the while being kept on antibiotics to keep things from getting worse. Yes, that’s right, 8 year old kids on antibiotics for months at a time.

        We took my oldest son to the US for MRI because getting it done immediately was important for a full recovery (rotator cuff injury) – it was a 2 month wait here. Treatment was completed here.

        Most of the time we just deal with the problems because MOST of us can’t afford to pay for our health care twice (once in our taxes, and again in going to the US.) That doesn’t mean we’re satisfied with what’s going on. Take a look at the great progress made recently in Alberta, just recently the gov’t released the official wait times list… it’s frightening.

    • Tim,

      I’m not claiming that everyone in Canada loves their health care system, just as I would not claim that everyone in the US hates theirs. There’s reasonable data that more people in the US are unhappy than people in Canada, but that’s not what this post is about.

      The topic of this post is that many people claim that it’s a common thing for Canadians to come to the US for health care. That’s not true.

    • Tim, I had to wait six weeks to get an MRI for a shoulder injury and five months to get an appointment for a basic physical exam (in a major metropolitan area with thousands of doctors). Don’t think for a moment that you’d receive better care or service in the U.S.

    • Tim,

      You are pulling our legs right?

      Most Canadians may chose to wait, but they do not have to wait. Private facilities are available for MRIs and CT Scans in at least the four most populous provinces


    • @Michael C —

      We do not have to wait? Bwahahaha! You clearly aren’t living in Canada with elderly parents or a child with a debilitating chronic condition.

      Are you trying to argue that we do in fact have a parallel private system, and that Canadians can choose to get their services from either the government or a for-profit clinic? This is not the case, even if you can Google up a site that appears to list a private health care system. Look at it — it’s mostly a conglomeration of clinics offering cosmetic surgery, physiotherapy and some diagnostic tests (I’ll pass on paying a $3300 annual fee to access a clinic, thank you very much.) Check out the actual company sites and look at the details.

      Fact is, we get a public health care system and in exchange we have to wait and the “quality” isn’t as good. Usually, that’s fine — I don’t need to sit in a plush leather chair to get a blood test, but sometimes it matters. A better example of wait times is for surgical procedures, like hip replacements etc.

      The system isn’t bad and can be improved. But we don’t have CHOICE and we don’t have a PRIVATE health care system.

      @Aaron — Point well-taken. Perhaps us regular Canadians think it’s more of an occurrence than it really is because our politicians, who relentlessly decry “two-tier” health care and maintain the anti-choice status quo, all too often are the ones who jump the queues and head to the USA when they need to (e.g. former MP and Cabinet Minister Belinda Stronach, Nfld Premier Danny Williams, the late former Québec premier Robert Bourassa, etc. etc.).

    • That’s not the only fallacy. I wrote about this a couple of years ago.

      Canadians actually have higher levels of satisfaction with their system than Americans. Only 12% of Canadians believe heir health care system needs to be rebuilt completely (see below), but 34% of Americans believe ours should be scrapped. Neither do Canadians wait longer than Americans for elective procedures and diagnostic tests. Canadian statistics show the average wait time for non-emergency, elective surgery in 2005 was 4.3 weeks and 3 weeks for diagnostic tests. According to 2001 OECD data, while 63% of US patients waited less than a month for elective surgery, 32% waited more than a month, and 5% waited four months or more.

      Additionally, the US ranks dead last in beating death from treatable illnesses. A study, by Ellen Nolte and Martin McKee of the London School of Hygiene and Tropical medicine, compared the United States to 18 other industrialized countries in averting preventable deaths. The study compared the rates of potentially preventable deaths from certain causes before age 75. Among the countries that did better than the US in preventable deaths were Canada, Australia, New Zealand, Japan, Finland, Portugal, the United Kingdom, Austria, Italy and Ireland. Even more troubling, the study indicated that between 1997-98 and 2002-03 preventable deaths fell by an average of 16% amongst all 18 nations. However, the US only saw a drop of 4%.

      The high cost of healthcare in the US also leads to citizens with chronic conditions not getting the care they need. According to a 2007 Commonwealth Fund International Health Policy survey, while 42% of surveyed US patients reported not getting care, skipping doses or not filling prescriptions because of cost, only 14% of Canadians did, 5% of those in the Netherlands, 9% of those in the UK, 20% of Germans and 28% of Australians.

      Finally, the meme that people come to the US for medical care is just a meme. The reality is that more and more US citizens are going abroad for care because they can’t afford it here. It’s even got a name “medical tourism” and is becoming so popular that US firms and insurers are starting to pay for it.

    • Tim,

      You would benefit from actually living in the US and getting a first-hand look at what the American health insurance system looks like. I pay thousands of dollars a year into Medicare even though I can’t use it; I then pay thousands of dollars for my own health insurance; then I pay a fee every time I go to the doctor; and then I get an additional bill from the doctor when the insurance company decides that it’s not going to pay a big chunk of the bill. I’ve had HMOs, PPOs, POSs – seven different insurance plans in 10 years across four different jobs – and they’re all the same. I’ve had to switch doctors four times because the plans all have different rosters.

      Oh, but as part of the lucky 50% of the country that has private health insurance, surely my care is better than what I got in Canada? Surely the doctor’s offices are so much more technologically advanced, and the doctors so much better trained, with so much more time to spend with patients?

      Yeah, I don’t think so. We pay a ton of money and then pay a ton more money when we get sick, and the entire system – aside from MRIs and orthopedic surgery, which you pay through the nose for – is no different than what I had in Canada. Dealing with insurance and having to change doctors all the time makes it even worse.

      I’d much rather wait to get a friggin MRI on my knee than go bankrupt because I have cancer.

    • Did Tim ever have to wait for a CAT scan?

    • Tim,

      If you’ll pass on paying a $3300 annual fee to access a clinic then you’ll definitely pass on the U.S. healthcare system! I have a child with spina bifida. Our deductible is $2700/year. We met the deductible the first week of February.

      I’ve had to access emergency care in Canada and I was very happy with the care received. I’m sure the Canadian system isn’t perfect, but one uninsured trip to a U.S. hospital will cure you of any envy you may have for our system.

    • “I’ll pass on paying a $3300 annual fee to access a clinic, thank you very much.”

      As a mid-30’s healthy single man, I pay $3600 annually for my health insurance. Based on historical trends, I expect this will quintuple (yes, quintuple: $18000) over the next ten years.

      That doesn’t mean that I actually get medical care for my $3600; it just gets me access to “preferred provider” rates, which are still very high but not as exorbitant as the misleadingly named “usual, customary, and reasonable” rates. If I were to get even moderately sick, the total amount I would pay would be $8600 yearly (until the bill reached $1,000,000, at which point my insurance plan would kick me out, I would not be able to get another, and I would become bankrupt and homeless and, shortly thereafter, dead).

      I don’t think you understand how bad the situation actually is down here.

    • I don’t know about heart transplants, but Canada did the first ever single and double lung transplants. Canadian doctors have also been pioneers in heart surgery.

      I think the comment ‘I’d much rather wait to get a friggin MRI on my knee than go bankrupt because I have cancer’ sums it all up well.

    • Bourassa received experimental treatment at the NIH so he doesn’t count. Williams went to the states on the advice of a physician he knew, someone who, with a phone call, would have found out that the procedure he wanted was available in Canada (as documented by Andre Picard in the Toronto Globe and Mail).

    • It seems like Tea Party types have no ability to think rationally… discussing things with them is like talking to a cat.

    • Tim wrote:

      The system isn’t bad and can be improved. But we don’t have CHOICE and we don’t have a PRIVATE health care system.

      I dearly wish those were my only objections to my country’s health care system.

      Here in the U.S., the private health insurance market does indeed give me a choice of vendors — specifically, I have the choice of what insurer I’d like to be declined by. I’m a fortyish guy in reasonable physical shape, but I have to take 4 prescription medications daily. The absurdly high prices of the drugs make me “uninsurable.” Therefore, I really don’t have a choice at all, because the insurance companies will not sell me a policy.

      So I’m one of the 50+ million Americans who are uninsured. All I can do is pay through the nose so the pharmacist will give me this day my daily meds, and keep looking for a new job that comes with health coverage (my last two haven’t).

    • Tim,

      We, too, do not have a choice. We must have private healthcare. And, believe me, we pay the price dearly.

    • Marvin,

      You need a new cat. My cat listens.


    • An interesting adjunct to this would be to graph the number of Americans who go to Canada or Mexico for more affordable prescription drugs or medical procedures.

    • Tim:
      I’ll bet a zillion bucks that if you were in the ER and the doctor thought you might have appendicitis, they would immediately give you a double-contrast CAT scan. If a doctor in Canada thought you were in impending doom, you’d get a scan.
      I have torn discs in my neck and I spend a lot of non-quality time with the US medical system. I have waited on lists for specialists for 6-8 weeks just for an initial appointment, weeks more for the MRI, a month more for another appointment, then waited another 2 months for the surgery to be scheduled.
      I pay more than $5,000 a year for my part of my employer’s health insurance, which has horribly high co-pays. All totaled I pay out more than $12,000 a year in out of pocket costs for insurance, co-pays, and prescriptions.
      So yeah, maybe you have to wait the SAME amount as we do in the US, but at least it doesn’t cost you the price of a new car each year – and my costs will only skyrocket in the next few years and as I get older.

    • Lets put it this way, there are more people without health care in US than the countries of Canada and Australia combined. Think of all the major to mid size Canadian and Australian cities. Then there are those who actually believe they have coverage until it is needed. Do people in canada lose homes , credit, jobs, dignity because of lack of health care. I put out about 20-25% of my nincome for care thats a joke , run by a for profit only company, just like most in US. Someone i know had stage 4 lung cancer and has full health coverage and recently had over $100,000 in bills. I also get most prescrips through Canada as I save a fortune for my insurance covers very little, for who can aford the US inflated prices !

    • This is actually a case of the grass being greener on the other side of the fence — the northern side to be sure!

    • Canadians are getting care for “free” (well, without out-of-pocket cost) when they see physicians in Canada. They pay going rates when they get care in the US, as I understand it, because their Canadian insurance doesn’t cover care in the States. Wonder how much cross-border movement there’d be…in either direction…if the out-of-pocket care cost were the same for an individual, regardless of the side of the border he received it on?

    • @Wally –
      Hey neat idea – we should have a joint Canadian-US healthcare system. Both countries pay into it from taxes. There have to be some economies of scale?
      Except Canadians would come out at a huge loss since their current healthcare system guarantees that they already have a healthier populous than the U.S. They’d have to start treating all of us unhealthy, non-preventive care folks south of the border and that would cost a whole lot. Of course I don’t blame them entirely — way more than 50 million Americans don’t get preventive care because they cannot afford it and/or have zero coverage.

    • the question is, do we know how many ‘medical tourists’ came to Canada for care, in the same time ?

    • A while ago I talked with a friend whose mom worked for the Canadian health care ministry. She told him that Americans crossing the border for care was the number one source of fraud in the Canadian health care system.

      I’d love to see current figures on this.

    • Only multi-millionaire Canadians can afford to go to the U.S. for health care. Because our additional health insurance does not cover “previous conditions” some of us can’t go there at all. I travel annually to the U.S. to see family there. The whole time I am there I am terrified in terror that I might suffer some ailment related to a previous condition. As far as I know, most Canadians needing to jump the wait-list queue go to Latin America or India for special medical care. I think we are blessed here in Canada, health-wise – blessed by the likes of Tommy Douglas – wasn’t he Michael Douglas’s grandfather?

    • Not Michael Douglas, he was Kiefer Sutherland’s grandfather (mother’s side I think).

    • I work for a law firm, and a lot of my job involves negotiating medical bills. Many of our clients don’t have insurance. I know how much an MRI costs and how much profit and overhead should be tacked on to that cost. I can tell you in all honesty that private patients with no insurance are being charged 300 to 500% MORE than patients with insurance or Medicare–that is, the patients least likely to be able to pay at all are being charged the MOST. If five different people walk into the emergency room with the same broken arm, all five of them will be charged a different amount for the same X-ray depending on if they have Medicare, Medicaid, private insurance like Blue Cross, worker’s compensation or no insurance at all. The uninsured are paying like it’s the “rack rate” at a hotel while the insured get discounts like they went through Expedia.com, only nobody gave them a choice. The facilities say they “have to” overcharge the uninsured patients to “make up for” the money they lose on the Medicare patients and the privately insured patients. If that’s not insanity, I don’t know what is. If you walked into a grocery store and were charged a different rate for your groceries depending on whether or not you had a job with benefits, you’d be madder than hell. In my opinion by far the best possible argument for a single payer Medicare like government run system is the getting rid of bullsh*t like this. And frankly, I don’t care how much it costs. We’re all paying for it already, in the form of charge-offs and bankruptcies when the uninsured can’t pay.

      • Like everything in the US it’s run by crooks and corporations ripping off everyone they can. I lived there for 7 years until I could not afford to due to potential medical costs and happily returned to Canada.

        Medical costs and charges in the US are calculated exactly like air fares. At least 15 or 20 different charges for the same seat depending on your ability to pay, but always the most expensive the airline can get.

        Americans are the biggest crybabies about the cost of anything such as $4.00 per gallon gas and the biggest braggarts and self delusionists about their system. It is only the shining city on the hill to
        dirt poor Mexicans and other central americans, the vast majority of other nationals would far rather stay where they are thank you.

    • Excellent point!! — “We’re all paying for it already, in the form of charge-offs and bankruptcies when the uninsured can’t pay.”

      I don’t understand why repubs don’t see this point. Not only are we paying for that, but uninsured also require more expensive care because they usually only seek care in a dire emergency once a condition has gone too far and not preventively along the way.

      I worked at a nursing home company and ironically it’s the opposite there. The private pay patients (who are mostly fairly wealthy to be able to pay for so many years of care) subsidize the medicare patients, whose payments do not fully cover care [at any semi-nice facility].

    • Aaron Carroll says: “Look, I’m not denying that some people with means might come to the United States for care. If I needed a heart/lung transplant, there’s no place I’d rather be. ”

      Correction. The United States is where you’d like to be assuming you had lots and lots of money or great insurance. If you were, say, an ordinary Arizonan in need of a transplant, you’d be dead, because the state is no longer funding those. One person has already died.

    • In answer to David and his query about the repubs not seeing the obvious, they do see but just don’t care about anyone who isn’t paying for their re-elections. That means us. We no pay, we no matter.

    • @Chuckie –
      Oh I actually meant the republican “citizens” who keep voting against their own best interest, not the elected officials. We already know that the “public servants” are owned by the corporations (dems to a small degree, but repubs have that [free] market cornered courtesy of the infamous K-Street Project).

    • So another way to look at this is that only 20 Canadians were brave enough to admit to a survey that they fled Canada to obtain satisfactory medical care in the United States. I think this study is clear evidence of severe fear in Canada.

    • As a dual, I can so not one of my family or anyone I know has gone to the States for care.

      Ye, there are certain hospitals in the US that are great. But not everyone has access to Johns Hopkins and the Cancer Center of America is also off limits to more than they are not.. You have to live IN the state of the great hospital as insurance is state by state.

      Conversely, insurance in Canada is provincial, but you can go to another province if you want to. Most will take the insurance from the province you came from. And even if you are new to Canada, the wait time to get onto the insurance is only 3 months as opposed to say, 2 years for medicare in the States.

      Furthermore, in Canada, life events do not effect my health care. If I am married to a creep, I may divorce without loss of care. If I get sick, I do not have to “spend down” to get care. When I am old, I will not have to give up my home and all assets in order to qualify for Medicaid because Medicare runs out ofter only 100 days in a nursing home.

      I will also be allowed to marry and not lose coverage as those on Medicaid in states lose coverage if married to a non-medicaid recipient. (Those on public plan Medicaid in the US are not allowed to save money, accept inheritance, work much, marry, or do anything to bring meaning to their lives. )

      AND Private insurance will drain you of thousands and thousands. If I paid into it over a lifetime, it would be hundreds of thousands of dollars while the CEO gets an 8.6 million exit deal……..and in the end, there is a cap on the life time total which may or may not be repealed via Obama Care. it’s all messed up in the States.

      Looking over the entire course of my life, I will save hundreds of thousands of dollars and have money to leave my kids if I choose. In the US, this is not possible.

      I have used both systems and see benefits to both, but over an entire life……… hands down, Canada has a better system.

    • Have you any figures on US citizens using the Canadian health care system, please?

    • This may give you an start. Here are some random notes and thoughts:

      The number of people who emigrate to Canada each year is around 20,000. Of course, most of those people will wind up using the Canadian system. I would venture a guess that some of those people emigrated because they wanted to live in a more equitable society and gain from this benefit (of course they’d be paying taxes while living there, so I assume they would be eligible for care).

      “An estimated 750,000 Americans went abroad for health care in 2007, and the report estimated that a million and a half would seek health care outside the US in 2008.” — Wikipedia. That is all the places they went abroad, so I’d bet that Canada is only a small part of that – maybe 30,000 tops?

      I have seen statistics from a 1996 Canadian survey that only 0.11% of Canadians have come to the US for healthcare. That’s around 36,000 people. Certainly not the “flocking” that Repubs make it sound like. Considering that the #1 voted Canadian hero is Tommy Douglas, it’s a sure bet that Canadians like their health care system quite a lot.

      Here are a few Americans who like the Canadian system: http://www.huffingtonpost.com/bill-mann/americans-whove-used-cana_b_215256.html

    • Probably one of the more civilized comment rolls I’ve see. I am struck by the number of comments suggesting that some supposed advantages in terms of wait times and other items for the US system just aren’t there.

      The trouble is in any of these comparisons is that theyare not simple ones, because there are no apples to apples comparisons that don’t have huge “yes, but-” factors.

      I do think the biggest matter, is that as a combined judgement:

      1. No other nation wants to mimic our system.
      2. When, nations such as Switzerland or Taiwan create a National Health system, they tend to move away from the US model.
      3. Our costs, efficiency/efficacy and outcomes don’t look very good in comparison to other National Health plans in the Industrialized World.

      That being said, for the US, it’s very hard to reverse course, so what has been done (i.e. AFCA), is probably though modest the best. I certainly think more of a public option would be great, but actually I think that will come when the appeal of screaming “socialism” becomes demographically less appealing.

    • Yes Eclectic, it is quite nice to see people actually discussing an issue rather than resorting to name calling when an opposing view is encountered.

      I live in the United States, and after watching Sicko, decided to do some research on the topic of private vs. universal health care. I am learning a lot, but it’s not an easy issue to resolve, especially here in the US.

      I read in another article where one person (Canadian) recounted that he was riding on a bus, or some form of public transport, and witnessed a young mother with her newborn child. He stated he found a sense of comfort in the knowledge that should that child become very ill, the young mother would not have to worry about whether or not she could afford to get medical care for her child. For him, that justified paying a bit higher tax rate. Imagine that.

      I really like that story. That’s what it boils down to for me. Concern for other human’s well-being. Stories like that remind me that there is still hope for us humans yet.

    • Ecletic you hit on something that has always mystified me. If the US system is as great as Americans seem to think it is, then why is it that no other country has adopted our approach????

      A think the reasons why are obvious. First, it’s too expensive. When you build in profits at every level, care gets to be expensive. Second, it leaves too many people uncovered.

      I actually have no problem with a “two-tiered” system. Have a bare bones state run system for the people who can’t get insurance through their employers or can’t afford it, and the “insured” system for anyone who can get insurance.

      Better to wait for doctors and procedures and know you can get care and not go bankrupt if you’re lower-middle class and can’t get or afford private insurance.

      It would be a safety net approach.