Hacker News Reader

> In my experience as a Canadian living in the US, I was basically shocked at how new, modern and efficient everything was, how service was relatively quick and how knowledgeable the experts were.

As a Canadian I have no doubt that the US healthcare is better than Canada's in many ways… if you have the money to get that care. Or you're willing to go into debt to pay for it:

> Two-thirds of people who file for bankruptcy cite medical issues as a key contributor to their financial downfall.

* https://www.cnbc.com/2019/02/11/this-is-the-real-reason-most...

However, Canada (and most of the Western countries) have lower infant mortality rates, lower maternal mortality rates, higher life expectancy, and a whole host of other health statistics. While often spending half on a per capita basis.

The 'health outcomes' comparisons are difficult, and not necessarily a measure of the healthcare system.

America has lower life expectancy because of violence, not healthcare.

That America has a cohort of poor people w/out care can easily drive a lot of the other numbers out of whack as well.

Finally, obesity, bad diet etc. - bad lifestyle choices are not a measure of the system either.

By and large, I view the American system as delivering better specific outcomes, without regard to price, all other things being equal.

Of course 'price' is a major factor as you indicate, and 'all other things' (diet, violence etc.) are not equal.

Isn't, from a macro perspective, 'numbers out of whack' due to a cohort of people without care, absolutely a measure of a broken system?

You may view the system as providing the best care for you, but that does not mean that the system is best in every sense?

If you want to view it that way, fine, but it's far more than just a 'system'.

It's like saying 'transportation' is one key to a healthy 'manufacturing system'.

If you are sick and you can have the choice between going to an American Hospital or a Canadian Hospital ... you go to the American one, because they are better, point blank.

Sure. If we compare individual hospitals' ability to treat one hypothetical person with the highest quality of service and outcome, you probably are correct.

But my impression is that is like saying that you are a better dad if you spend all your money on one of your kids' Harvard education and let the other one fend for himself or go into debt, when you could've given them both adequate education at a less expensive college?

My position is simply that a health ecosystem where everyone gets adequate care for free or at least without going into crippling debt is preferred over a system where some get lavish care and others none. It's not like there's a thousand people dying of perfectly treatable diseases due to queuing in the Canadian health care system - but there are indeed people dying because they can't access basic care in the American system.

By the way: When is transportation not a key to efficient manufacturing? Do you think that the efficient solution is for factories to make every single part of their product on site? Does it not matter whether spare parts for machinery can be ordered and delivered within 24 hours instead of 24 days? Or did you mean that what I said was obvious, i.e. the American health care system is clearly less efficient for providing solutions to the population than the Canadian, but you want to stress the point that it is possible, in some cases, to get better individual care in an American hospital?

> America has lower life expectancy because of violence, not healthcare.

Opioid epidemic, violence, and healthcare system all play a role, both in life expectancy and quality of life.

> By and large, I view the American system as delivering better specific outcomes, without regard to price, all other things being equal.

What does this even mean? If it means choosing random encounters for equivalent similar conditions, and ignoring price, the outcome in the US is consistently or on-average better, I don't think that's true.

If you mean “where can the best care be acquired, without regard to how many people have access to it”, sure, that may be correct.

"What does this even mean?"

It means they have better Doctors, better processes, better equipment, more of it.

It means if you have a problem, and want to 'be fixed' - you would much prefer to be in an American hospital - the only question is 'can you afford it').

Rich Canadians go across the border to the US all the time for care.

> America has lower life expectancy because of violence, not healthcare.

> That America has a cohort of poor people w/out care can easily drive a lot of the other numbers out of whack as well.

Other countries help probably take better care of their poor with social programs, which would include healthcare (IMHO). See also higher taxes, which allows for redistribution of wealth and paying for said programs.

>> Two-thirds of people who file for bankruptcy cite medical issues as a key contributor to their financial downfall.

Only 4% of US bankruptcies are because of medical bills (https://www.washingtonpost.com/blogs/post-partisan/wp/2018/0...). A tipoff that [insert large percentage here] of bankruptcies aren't actually because of medical costs is that only 6% of bankruptcies by those without health insurance are because of that cause. The biggest cause of bankruptcies is lack of income, which health insurance doesn't affect.

I think you may paint an overly rosy image of American health infrastructure. Where you live inside the U.S. has a huge impact on how "new" the available medical equipment is and how "knowledgeable" your local experts are.

What's more, most insurance is not generous. The insurer becomes the rationer of care by requiring value interventions before more expensive ones. Essentially any interest a state has in reducing costs an insurance company also already has. The main difference is that the insurance pool is probably healthier than the "everybody" pool.

Lastly, even if it is true America's system features better cutting edge medicine, I really doubt making the system less profit motivated would affect global health innovation. Perhaps a bit but quickly governments would realize they are going to have to invest in research more rather than purchase innovations from the U.S. This may actually increase the value proposition of research because there would no longer be a single locus drawing all competition for specialized labor.

"Perhaps a bit but quickly governments would realize they are going to have to invest in research more rather than purchase innovations from the U.S."

Governments are not this sophisticated or operationally nimble unfortunately.

We're in a pandemic, and I watch our Provincial medical leaders come out and talk almost every day, they're all smart, but they don't really understand what is going on - they don't have the data. But in a pandemic that destroys 20% of GDP, maybe it would be a good idea to have every single person who takes a COVID test fill out a questionnaire, so the data can be made available? Masses of unemployed young people that could be put quickly and succinctly onto large-scale contract tracing programs? Releasing communications apps to collect data, getting national level experiments running to determine the primary vectors of propagation etc. etc..

They are all professionals with good intentions, but this does not remotely translate into operational effectiveness. What we need is a 'Dwight D. Eisenhower' kind of leader for this pandemic but his type is long gone and we may not even recognize operational efficiency.

Even during a pandemic when much is at stake, they're limited by their own systems. A much broader strategy of 'creating innovation to make up for the American loss' would't work, even throwing $ zillions at it wouldn't solve the problem.

The sophistication of Canadian products, and ironically economic diversity has been going down in Canada, as we focus on being 'really good' at being a good 'Foreign HQ' country.

My most recent hospital visit here in Quebec was a little scary: broken equipment in the main hall, the water fountain out of service, having to wait in a cold waiting room all day for a very small issue with no updates (and I couldn't even leave the room), the halls were lined with elderly people in beds because they were overcapacity. I did receive competent care, but the economic stresses were visible.

And of course I don't doubt for a second how insane the US system can be for billing, financialisations etc..

I think the US should be looking towards the Dutch or Swiss models, not Canada or UK.

All of your characterization of the Canadian healthcare system nearly equally applies to the U.S. There are many older hospitals here with broken equipment and which become easily overwhelmed.

As for unsophisticated but well intentioned provincials that is a problem here as well. My own uncle passed from a cancer which was diagnosed as non-aggressive by a rural for profit hospital yet later rediagnised as extremely aggressive at a more sophisticated facility 2 years later shortly before his death. Geography and demographics create provincialism, organizational structure obviously has an impact on how we respond to that difficult problem but regardless of if a healthcare system is for profit or not, a nation is simply not going to commit the same resources to rural areas.

To my mind, the more surprising thing isn't how different the problems of American and Canadian provincial care are but how much the same they are.

Regarding

> Governments are not this sophisticated or operationally nimble unfortunately.

I don't know that this is true. Governments collect and act on a lot of public health information.

And you still have a double digit risk of being screwed even with a reputable insurer. Legalese, and fine script in medical services is a minefield no worse than American financial laws.

Exactly - every detail of insurance plans are a scam, and that’s not even enough so they’ll just deny valid claims and make you work for it.

An MRI might be “covered” but what if you have to spend 2 hours getting it approved beforehand and then 2 hours after proving that they said they’d cover it? Every time? For 4 MRIs?

The US system rations care as well. It just rations on the basis of who can afford care. It seems much more logical and humane to ration care based on how essential the service required is.

The US system also rations equipment based on more or less arbitrary bureaucratic determinations. Want to open a radiology practice with an MRI machine? Better hope the state lets you.

bbdog is correct to point out that rationing is mostly economic.

I do agree that there should be a humanitarian component to it.

In Canada, it's the other extreme: everyone is treated identically (theoretically) no matter what and it's illegal to sell medical services in most cases. The way 'around' the problem is to hunt down good doctors through the network and word of mouth. Literally the Golf Club is where you find out who the best docs are, and then you apply with them and hope you have enough clout/status that they take you on as a patient, because otherwise you just get 'stand in line at the clinics'. Doctors have their own hierarchy/status, and you want one on the 'inside'.