Wednesday, October 17, 2007

Universal Health Care: What Are We Waiting For?

As is my custom, I was checking out news items on the Web addressing health care, when I ran across an interesting report. It is about a study of wait times (time from diagnosis and referral by a primary care physician to performance of the procedure by a specialist) in the Canadian health system for five procedures: cataract surgery, cancer treatment, joint replacement, heart care and diagnostic imaging. You can also read about it here.

Regular readers will know that I am an advocate of a system to provide universal access to health care. Many folks, both advocates and critics of changing the American health care "system" (sometimes it's hard to apply the word "system" to something so disorganized), look at the Canadian system for comparison. And when we do, these wait times certainly constitute a major issue. It is the most common issue, I think, raised by American critics.

Now, there are some valid questions to be raised about the method and meaning of the study. First, it's very important, I think, that these are wait times for elective procedures, and not emergency or urgent procedures. These were patients that doctors thought could safely wait. Presumably, emergency and urgent cases were served in an emergency time frame.

Critics have also noted the percentage of doctors contacted who responded to the survey (less than 30%) with no reported analysis of possible differences between those who did and didn’t choose to respond. The question raised by some, for example, is whether those who were dissatisfied with long wait times were more likely to respond than those who were satisfied.

Another question I have is about the choice of these five specialty areas. They do, perhaps, offer a broad view of health care delivery. At the same time, they seem so disparate, especially in the liklihood that a procedure might be life-threatening, as to muddy comparison; or at least to confuse interpretation. After all, waiting for a cataract surgery vs a cardiology procedure would seem so different in risk as to skew comparison of patients' (or public) perspectives.

And for American critics, let's not pretend there aren't wait times in American health care. There are certainly wait times for elective procedures, if not so long. More critical in the US, unlike those measured in this report in Canada, are wait times to see a physician in the first place even to determine whether a symptom or condition is urgent. Those wait times and access issues are a major factor in inappropriate use of emergency services, and in patients neglecting preventive care, both of which raise health care costs overall.

And yet, wait times are a matter for concern, both for Canadians seeking procedures, and for Americans looking for ways to provide health care to more of our citizens. Which is why I noted in the news report the suggestion of Nadeem Esmail, one of the study authors.

To solve the problem, Canada should look at the seven European countries that spend the same or less on health care as this country for universally accessible systems but have no wait lists to speak of, Mr. Esmail said. What they have, and Canada does not, is user fees that prevent needless use of health care, competition between public and private operators for public health funds and a separate private system that can siphon off some demand, he said.

I think there are two points to note here. First and foremost, in looking for ideas for improvement Mr. Esmail does not look to his neighbors to the South. He does not look at our “market-oriented” system.

Rather, and second, he looks to European models that manage to provide universal access without the more significant wait time and waiting lists. The brief description he offers highlights an important role for government in providing universal health care. It is not “socialized medicine,” with government ownership of health care institutions and employment of providers – the straw man of health care conservatives. Instead, the systems he points to have universal participation (some responsibility for those receiving care) and what we speak of here as public/private partnerships. They have systems in which interaction between the government and private interests, that might include competition or cooperation, can still provide universal access.

This is an interesting study regarding wait times in the Canadian health system, and I’m sure we’ll here about it again – probably from health care conservatives trumpeting the flaws of the Canadian system. But if we read in more detail, there is much with which advocates for universal care can challenge them: other models somewhere between the poles of true socialized medicine and “market-oriented” inequity. If we can acknowledge that universal coverage is not only morally desirable but also economically possible, and can look for new models to provide it, perhaps we can make progress toward providing care for all our citizens.

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