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Comment by raganwald | Hacker News Reader

What I find interesting about the "We beat Canada" idea is how few Canadians move to the USA in search of better health care. Rich Canadians take advantage of the porous border by travelling to the US and paying for certain procedures, but generally when someone permanently moves from Canada to the US, it's always in search of economic improvement.

I would like to see statistics showing that Canadians would happily take a job with the same or worse pay just to get access to US health care. If the US system was superior in ways that mattered to people, we should be able to measure this effect by looking at immigration.

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Public healthcare is a cornerstone of Canadian national identity, in part because we recognize how bad the American system is. There are always ideologues who are inspired to emulate the American system, but they never get any traction with the electorate because healthcare privatization is the third rail of Canadian politics.

If Canadians move to the US it's in spite of the American healthcare system. I've never heard of anyone emigrating because they thought it was an attraction.

In fairness, as a Canadian living in the US, if I were really rich I might move here because of the quality of healthcare I could get. This doesn't mean the system does the greatest good for the greatest number (by any stretch).

The US is easily the best country in the world in which to be rich.

Possibly. I have to believe that Donna Dubinsky is pretty well off, and she still had complaints about American healthcare.

The minute number of people who are able to chance paying seven-figure medical bills out of pocket might enjoy the US system, but I doubt that group encompasses even a majority of 'rich' Americans, by any reasonable definition.

Immigration requires a whole lot of push. Given how many Canadians already live within easy driving distance of the US border, even gigantic differences in efficiency and quality wouldn't drive much actual transnational immigration.

You move across a border for a better job, not to potentially shave 45 minutes off your wait time after a putative future cycling accident.

If we were confident that the friction of immigration exceeds the allure of better wait times, then we can say with some confidence that better wait times simply aren't that important to people. Or at least, not as important as making more money, or retiring to a warm place, or hanging out where the action is.

If it doesn't rank next to those other reasons for immigration that all exceed the friction, I would suggest that people stop defending the US system by saying it's better than Canada's system. It isn't better enough. If you like it, fine. If you don't like it, fix what you don't like. But arguments that it's better than Canada should be accompanied by evidence that it exceeds what is actually an incredibly small amount of friction.

I mean, come on, it's not like you have to learn a new language or give up your love of Hockey to move from Canada to the US. If you have a university degree the whole thing is fairly painless.

p.s. On second reading, I see you talking about driving across the border for "Medical Tourism." To my understanding, this is inconvenient for seeing a GP or a specialist, and while some people consider it worthwhile for an MRI, it is not possible to buy into US medical insurance that would cover anything really expensive.

So effectively, medical tourism is equivalent to being completely uninsured in the USA. I don't think anyone argues with a straight face that being uninsured in the US is superior to being subject to the horrors of Canadian medical care. My understanding is that people argue that being insured in the US is more convenient than being a Canadian. If I thought that being insured in the US was superior to Canadian health care, I wouldn't reason that driving across the border for an MRI somehow gives me the best of both worlds, I'd want US insurance so that I could drive across the border for a heart transplant.

And for that, I'd have to move to the US and suffer the same slings and arrows of outrageous deniability fortune suffered by Ms Drabinsky when she tried to insure her family.

"If it doesn't rank next to those other reasons for immigration that all exceed the friction, I would suggest that people stop defending the US system by saying it's better than Canada's system. It isn't better enough."

That's fine. I assume the reverse, asserting that the Canadian (and European, and ...) systems are better is also a no-go, given rates of immigration there from the US?

I just don't think anyone's going to move anywhere for health care systems unless they're already sick and they're going for medical tourism purposes. Use of the health care system is a nebulous future possibility, whereas a job or the weather or the cultural environment is an everyday reality. Immigration rates aren't going to tell us much about any health care system.

(edit: specifying the final object)

But arguments that it's better than Canada should be accompanied by evidence that it exceeds what is actually an incredibly small amount of friction.

Very true. Since very few people move from one industrialized nation to another for the health care, we should conclude that they all provide very similar services.

Well, we can conclude that they are not as important and/or as urgent as other factors, and only for those who are mobile. Between Canada and the US, for example, it is easiest to move if you are young, educated, and employable. So I might draw some conclusions about the lack of difference to those who are young, educated, and employable.

I wouldn't assume that there's no difference for someone who is older, uneducated, or unemployed, because the cross-border friction is WAY higher for them.

And of course, all we are talking about is perceived benefit. If one system costs a lot more than the other, we can make all sorts of statements about that. Is the Canadian system more expensive? Is the American system more expensive? I've seen both arguments given, and it looks an awful lot like you can juggle figures at will to justify either claim.

I wouldn't assume that there's no difference for someone who is older, uneducated, or unemployed, because the cross-border friction is WAY higher for them.

You might be right, but I don't think you can simply assume it.

For example, a well-educated, professionally employed person old enough to have an established family is highly immobile for those very reasons. Their jobs and their family ties are holding them in place. Who knows how these factors all net out.

Are we in violent agreement? I said that I wouldn't assume because the friction is higher. I was thinking along the same lines as you, but perhaps I should have been explicit that I include factors like family ties and roots in the community as part of 'friction.'

I agree, it would be nice to see some data on that.

A few days ago we had a discussion here on HN about the viability of Montreal as a startup hub, and when I raised the question of what Canadian cities in general could do to counter the higher pay and better climate down south, I somehow completely forgot (as did any responders) about the potential advantage of our kinder (if at times sluggish) healthcare system, especially in light of medical tourism options.

I think that's part of the point of the graph. Yes 'we beat Canada' but not by enough that it matters at all.

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