perfidy

Being genetically designed for cave-dwelling, my recent trip to British Columbia's Sunshine Coast had predictable results. Two days in, I had a nice sunburn/sun reaction. I've seen it a dozen times before and I know that seeing a doctor is a good idea when it gets severe. Since I haven't lived in Canada in ten years, I don't have a provincial health card any more. I therefore entered the BC medical system as a simple cash-carrying person (yes, we do have that in Canada).

I called in the morning, and had an appointment for that afternoon. The doctor and I spent about 15 minutes together, and I walked out with my prescription. Let's tote up the costs:

$40 for the office visit, cash. $9.32 for the prescription. Both those figures are in Canadian dollars, so at today's exchange rate my interaction with the health system cost US$36.57.

About two years ago the same thing happened while here at home. I did get an appointment for the same afternoon, but I had to wait about an hour and a half. The 10 minute office visit cost around $65 (covered by insurance, but shouldn't we look to see how much we're being charged). The prescription cost about $20, for the same medication; our interaction total is about US$85.

There's no discernible difference in the quality of care received, for an interaction like this, between the US and Canadian system. So why do we have such a difference in charges to the patient? There's a laundry list of reasons, I suppose. Doctors in Canada don't have the same vulnerability to malpractice; there's some legislative protection, and large jury awards are almost unheard of in Canada. Staffing costs are higher in the US, which means higher costs to cover.

One of the largest factors is the massive administrative and paperwork overhead in the US system. This burden is estimated to chew up almost 30% of medical dollars; it's the constant paper cut knife-fighting between physicians' offices' admins and their counterparts at the insurance companies. The insurance companies don't want to pay out; the longer they can hold on to their dollars the more they earn on investments. Most doctors in the US have at least one and usually more people on staff who work payment issues almost full-time.

Administrative overhead in the Canadian system is about 6%, and other socialized medicine systems run about the same.

I think the medical insurance companies are at the heart of this. An ob-gyn friend has just been presented with a Faustian deal by her malpractice company; either sign a new agreement with a "tail clause", or lose her insurance. The malpractice insurance policy used to cost $85,000 per year. The "new deal" is that if she ever ceases insuring with this company, she must pay them two years, in full upon doing so. Malpractice insurance companies are local, so if she moves to another state, this amount would be due and payable.

So she should just go to another insurance company, right? Wrong. Malpractice insurance is highly specialized; it turns out that in our area, there is exactly one company offering malpractice insurance to ob-gyns. Of course, that company is likely owned by another, much larger company that does national health insurance, but for the purposes of this contract it is irrelevant.

Her practice of (I believe) eight ob-gyns are all being forced into the same deal. Some of them are nearing the end of their careers or don't have any plans to move; for them the deal is still possible.

There's a bizarre little circle at the heart of the system. That first $85,000 in revenues is paid by insurance companies and then routed right back to insurance companies. We know that the payout rate for medical malpractice insurance is around 4 to 1; for every four dollars taken in, one dollar is paid out. Mathematically, this tells us that the insurance industry needs to keep malpractice underwriting small and local; only when the risk is concentrated can the premiums be justified. In the aggregate malpractice insurance is rather profitable.

By shifting money into the malpractice stream, the cost of health care has been exaggerrated. Insurance companies have dramatically raised their rates over the past four years, citing increased costs and malpractice, when they themselves are the primary reasons for those cost increases.

For those Americans looking for affordable health care, you might want to look north of the border. For the cash-paying patient, it's prompt and efficient, and less than half the cost of American care of comparable quality. Powell River British Columbia has noted a recent trend -- medical tourism. It seems that the excellent hospital and ready availability of care has recently been drawing patients from Canada's urban centers, as well as from the US.

And just to head it off, I'll admit that the finest health care in the world is available right here in the US. Of course, only a tiny fraction of the population can actually afford it, but who the hell cares about the rest? Paying twice as much to insure only 60% of the population is the American Way; that paperwork and overhead is the heart of the system. And private medical care must be preserved at all costs! Private care like you can, uh, get in Canada.

Imposing a system on the population that benefits and works for only a small number of people? That's real elitism; the kind that takes food from children, breaks a man's life with medical expenses, laughs at the suffering, and guides the body politic to cement it in place.