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Comment by jaarse | Hacker News Reader

I’m a Canadian, and I would never want to give up our single payer system.

That being said, Canada has a huge health care problem right now. Frequently they need to close emergency services in major (& minor) cities at night due to staff shortages. The wait times for basic diagnostics is on the order of months (not days or weeks). For example, a relative of mine has lost 90 pounds since the start of the year, complained of chest pains and couldn’t (still can’t) swallow. They just got a basic scan after 6 months of waiting to confirm a baseball sized tumour in their lungs.

For many years we ran with just the bare minimum of staffing and equipment to keep costs low, and now, due to a number of factors our system can’t keep up.

Waste is not good, but a little bit of extra capacity (and cost) isn’t a bad thing when it comes to emergency services.

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Much of the current failures are due to conservative provincial governments (looking at you, Ontario...) purposely underfunding before and into the pandemic.

We are now reaping what they have sown.

This is a classic "underfund to prove the system doesn't work thus we must privatize it!" move.

How much do you estimate this is being underfunded, and do you believe proper funding for healthcare would push the percentage of GDP closer to the US number?

You're assuming the US healthcare system isn't equally underfunded. The US has massive doctors shortages (especially in rural areas), and that's not counting all the care the US just doesn't do because people instead just die since they can't afford to go to the hospital.

> You're assuming the US healthcare system isn't equally underfunded.

You don't have to assume. It costs twice as much as the most expensive health systems on earth, but delivers Afghanistan-level life expectancies. The problem isn't that we're spending too little.

And yet people skip tons of routine checks because they cost too much.

I have really no opinion on any of this, but please realize there are more factors than health care on life expectancy.

What is a better metric and how does the US do on it?

Infant mortality (but that's also tricky because of differences in reporting between countries), cancer survival rates.

Life expectancy is a particularly bad metric to use to compare health care systems, because it's heavily influenced by (1) how much people drive, (2) how much violent crime there is, and (3) how much drug addiction the country has. None of those are health care metrics.

I don't believe there's any credible critic of American health care that premises their complaint on America delivering bad health care. We deliver pretty excellent health care, and we deliver it faster than a lot of countries with better health care outcomes. We are in many places in the US overprovisioned for care (by measurements like empty hospital beds, or overprescription of elective procedures). The chief complaint about American health care is how expensive it is, not how good it is.

That distinction is especially important because getting costs down may involve confronting the ways American care is better than it needs to be or should be. For instance: we do a lot more elective surgeries than countries with better outcomes, in part because we do them outpatient here, and they're inpatient (a much bigger deal) elsewhere. For example, my understanding is you're much more likely to get a hernia repaired (probably needlessly) here than in the UK.

I don't know, but almost everything is more complicated than people often make it out to be. Unless you'd like to spend 40+ hours/days/years researching it, you're probably better off trying to be more laid back.

If you are going to use life expectancy you should at least not use hyperbole to compare. It would be fair to claim the US spends the most on earth but only gets Polish levels of life expectancy.

Afghanistan is a whole decade off that cohort.

Ontario is consistently the lowest spender per capita on health in the country.

Ref: https://www.fao-on.org/en/Blog/Publications/interprovincial-...

It's being underfunded by at least 10-15%, which is a lot for a system expected to run as cost effectively as possible. I'm getting that number from the average of $5336 vs ON at $4800. 4800/5336 = ~89%

I don't think we should aspire to US levels of GDP share. That seems quite excessive.

I think the solutions to our issues are structural changes and adequate funding.

It seems a bit strange to call out the Conservatives specifically. Ontario has been purposefully underfunding healthcare for decades upon decades, with most of the damage done decades ago. Peterson (Liberal) forced practitioners to operate under fixed rates defined by the province, which even lead to a doctors strike. Rae (NDP) eliminated 8,000 acute care beds. Harris (PC) eliminated another 6,000 beds.

Governments of the last 20 years have held the status quo, which leaves them equally culpable.

Conservatives hate that their money is taken away to fund poor people and take money away from their rich friends, and it brings them to defund healthcare, liberals hate that it creates a natural monopoly and their inability to see a functioning society work without private hospitals brings them to defund healthcare

There's no point pretending you know what people's motivations are. Conservatives I've read/heard seem to generally want similar outcomes, but disagree drastically on the methods.

First sentence: don’t guess people’s motivations

Second sentence: explain people’s motivations

No, that's a category error. I'm not talking about every conservative. Just the ones I've listened to explain themselves.

I believe that guess and explain are two different verbs

This is happening in the UK too.

The NHS is still wildly popular so it's politically impossible to privatize from the outside in but it's becoming less popular as its effectiveness declines due to expanding mismanagement, underfunding and corruption when awarding contracts.

The frog has to be boiled slowly though.

> The wait times for basic diagnostics is on the order of months (not days or weeks).

The crazy thing to me about this is, most Americans simply skip medical procedures, or tests due to cost.

So American wait times aren't lower because their hospitals are better, they just server a much smaller pool of people due to so many being priced out of being healthy.

And honestly, the longer you go without doctor visits, more expensive, complicated and involved the process is.

This is a gray area too as unnecessary testing can be costly and lead to worse care: https://www.npr.org/sections/health-shots/2022/06/13/1104141...

“Most” Americans do not skip procedures due to cost. About 1/3 have (https://www.kff.org/health-costs/issue-brief/americans-chall...) and that is mostly dental procedures.

That is an atrocious number and something that needs fixing but we don’t need to exaggerate it to make that true.

Good link there, but assuming I’m looking at the same section as you, it seems like the 1/3 figure is for skipping or delaying tests and treatments recommended by their doctors, which doesn’t really tell us how many people forego seeing a doctor altogether due to cost concerns.

Technically it was 1/3 had or had family members, which means the number is actually much better than 1/3 but I was being generous.

We don’t know how many people skip healthcare because a doctor is inconvenient (in the states or in other regimes) either. So it seemed the most appropriate comparison to make.

That's the lowest percentage out of all the sentences from that paragraph.

The 1/3rd is people avoiding treatment recommended by a doctor. 43% of people reported to have avoided healthcare due to costs.

To me "Not most people, only 43%" isn't what I would consider too much of an exaggeration.

Well, I'm here in a major metro area of the US and it's 6 months or more for every doctor I try to see. Very difficult to get in to see anyone for anything.

What's that major metro area? I'm in San Francisco and I have family in Boulder and in both primary care is like one or two weeks. Dermatology was a week and a half for me. A few months ago I needed imagining for a foot thing and it took three days for ultrasound and one week for an MRI. I thought this was the norm on big urban centers.

I live in a suburban area and I go to the doctor for completely random things for my kids because it’s so easy. I can get appointments to be seen within hours.

Midwest, large city; pediatrician is same day, Allergist same week, Developmental Pediatrics was 4 months, Pediatric Ophthalmology was a year, it really varies. I'm lucky to have all these specialities available, people drive 2 or 3 hours to use the Midwest Eye Institute.

Every "Family" doctor has stopped practicing or gone to a no insurance model that caters to wealthy people. You can only get "internal medicine" doctors for primary care. I've seen waits ranging from 4 months to a year, depending on what your dealing with.

It's also impossible to get a 2nd opinion. The specialists all tend to belong to the same groups so you'll call a different doctor and eventually get shunted back to the exact same doctor you started out with. Where the the competition?

Chicago. My actual GP schedules months out. An appointment with "any doctor in their practice" is within a week. An appointment at their affiliated urgent-care takes hours, usually less. The correct strategy is to get a GP affiliated with an urgent-care, schedule a checkup with the GP, and, meanwhile, just go to the urgent-care for everything; they'll send records over to your doctor if there's anything complicated.

Chicago, I can make a televisit appointment to my primary care doctor typically with 1 day lead times. In person is typically 2 so he can schlep down to his office. He is a single practitioner with part time office and IT help. He recommends going to the minute clinic a block away from my house for most things that I can recognize and only calling him for a yearly consult which is a review of blood tests and a discussion about my health or for something the clinic didn’t figure out.

This seems like a completely reasonable approach and I’m always surprised that it’s not the default.

To be fair, I think at least some of that is burned out healthcare professionals quitting after two+ of pandemic ridiculousness.

(Ridiculousness not being the pandemic itself, but inadequate resources, planning, and political cover from all levels of government.)

>Frequently they need to close emergency services in major (& minor) cities at night due to staff shortages. The wait times for basic diagnostics is on the order of months (not days or weeks).

Part of this is COVID burnout. It wasn't this bad in 2019. Wife works in healthcare and sees the difference every day. Nurses crying etc.

For what it’s worth, this experience isn’t entirely uncommon in the US either. I live in a rural area that has a trauma center and a hospital because it is X distance from the next closest hospital and gets money from the state/county to exist. But that is all they are. Outside of diagnostic imaging and very basic healthcare, you are shipped off to either Portland, Seattle, or in some cases Idaho. Everything is backed up and it is largely due to a lack of personnel because people are just not joining the field. It is basically the inversion of your problem. We burn out everyone who works in a hospital specifically because of the pursuit of profit. They’re all understaffed and everyone works shifts that are unsafe due to their length to compensate. Hospitals are an incredibly stressful place to work and doctors and nurses have inherently difficult jobs. Yet they’re treated largely like disposable assets to be burned through. It is bad for patients and it is bad for the staff. But it is apparently good for business.

And also...

For many years Canada (and similar countries) have relied on cutting costs by importing health care professionals from other countries. That pipeline has now shrunk considerably, resulting in the exposure of the underlying problem.

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