Americans are not ready for socialized medicine

[ERCougar]

Originally Posted by tooblue

Fear-mongoring • see: CardiacCoug's post

I don't think the scenario he paints is totally outside the realm of possibility. I'd be curious to see how Canada and Europe handle stenting; it's outside my field, so I don't know. There is good evidence to suggest that stenting isn't any more effective than medical therapy (except in the case of an MI). However, once you're already in and doing the angiogram, it seems kind of silly not to stent. I guess it depends on how much cost stenting adds to the angiogram. Any idea on this CC?

This is outside my field, so I don't know how Canada handles stents; I suspect CC knows, however. In emergency medicine, there is a fair amount of rationing that goes on when compared to here. Some of that's a good thing, cost-wise (and care-wise); we should be doing FAR fewer CT's than we are, for example. However, doctors don't face nearly the same malpractice threat. Anyway, knowing how things are done in Canada in emergency medicine, it wouldn't surprise me at all if they stopped stenting asymptomatic blockages in Canada.

[ERCougar]

Originally Posted by Ma'ake

I agree, on both points, but there's just no way Obama (or anyone else) can do a HillaryCare (or Canadian or UK) solution. It simply won't work in the US, not now, likely not ever.

The two biggest problems areas in US healthcare are insurance and Rx $$.

Competition between the private & public sectors on health insurance will help drive costs down, overall, and force the private insurers to become more efficient. No matter how successful the public insurance plan(s) might become, there will always be a market for private insurance, for supplemental insurance if nothing else.

Expectations in other nations of a completely egalitarian system won't be a problem here. Americans are used to the idea of paying extra for expedited or premium service. It's that way in air travel, sporting events, etc.

If you're the 40-something athlete & don't want to wait for your MRI, there's nothing preventing your from ponying up $$ to have it done sooner, or paying the supplemental insurance to get expedited service.

Regarding Big Pharma, why shouldn't the American public get the same price the Canadian public gets? If there is cost shifting on research funding, end it, make the Canucks & others share the costs. Right now Big Pharma sticks it to the American consumer because they can.

The market for supplemental insurance is not robust in Canada or Europe, to my understanding. It exists, but most don't take part.

It sounds like you're advocating a sort of expanded Medicaid with fewer benefits, with extra services covered by private insurance. I think I could go along with this. However, states have been free to do this for years (as it's the states that essentially control Medicaid), and few have tried, and the few that have tried have not been very successful. Perhaps it's impossible to do it on anything less than a national scale when you have employer-based insurance and multistate corporations involved--I don't know.

I agree that cost-shifting on drug research needs to occur and the market opened up. I think this is already occurring to some extent as well on an individual patient level.

I still think that the average American thinks that socialized medicine would offer them the same care they have access to today, but with no costs. That's not going to happen. We would have to cut back Medicaid benefits if we want to expand eligibility--Medicaid already goes beyond what represents a basic level of healthcare. In fact, the poor uninsured here probably have it better than what they would have in Canada. If you want to duplicate the cost-savings of socialized medicine, you necessarily have to ration care. I don't necessarily have a problem with that in most instances, but I'm telling you--many Americans are going to.

And you have to accompany it with tort reform--something the Dems don't want to touch with a ten-foot pole.

Even with those two measures, I'm still not sure we can reach the cost-savings, without addressing some of the deeper causes of poor medical outcomes--causes that have nothing to do with the healthcare system.

[exUte]

Originally Posted by ERCougar

I think there are a lot of efficiencies to be gained by socializing medicine. However, I'm concerned that Americans just aren't ready for it. They've been spoiled for too long getting what they want, now. Wait until someone tells them no, you can't have your MRI of your knee because frankly, the government doesn't care if you're a future all-star of your city league over-40 basketball team. No, you can't have the newest blood pressure medicine because it costs 20x the amount of the old one that makes you a little more tired when you run. No, we're not doing another EKG today because you've been here 18 times this year for chest pain and it's never amounted to anything. No, we won't do a Vitamin B12 level to check out that tingling sensation in your toe. No, we're not going to keep your 80 yo father in the ICU for the next month hoping that he turns a corner.

I'm obviously talking about Americans with good insurance, but a lot of this applies to Medicaid patients, who in some cases, have the best insurance out there. But these Americans with good insurance are the ones in power and they're not going to stand for rationing. Any sort of socialized program akin to Europe or Canada is going to be extraordinarily expensive because of this.

aware of the unintended consequences you describe. In this politically correct nation and with Dem leaders calling those opposing such a plan as bigots (or some other name calling), they will succumb and figure it out after the fact.

[Ma'ake]

Originally Posted by ERCougar

I still think that the average American thinks that socialized medicine would offer them the same care they have access to today, but with no costs. That's not going to happen. We would have to cut back Medicaid benefits if we want to expand eligibility--Medicaid already goes beyond what represents a basic level of healthcare. In fact, the poor uninsured here probably have it better than what they would have in Canada. If you want to duplicate the cost-savings of socialized medicine, you necessarily have to ration care. I don't necessarily have a problem with that in most instances, but I'm telling you--many Americans are going to.

And you have to accompany it with tort reform--something the Dems don't want to touch with a ten-foot pole.

Even with those two measures, I'm still not sure we can reach the cost-savings, without addressing some of the deeper causes of poor medical outcomes--causes that have nothing to do with the healthcare system.

Good points, all, which is why a pure Canadian style system won't fly. Incremental changes can be made, but people will have to adjust their expectations to a different equilibrium. There is no free lunch, and like you allude to, there are lifestyle problems that exist no matter the system.

I read somewhere the Canadian Supreme Court recently ruled it is permissible for providers to accept private payment, ie, patients could move up in line with extra $$ in hand. That alone tells you how far apart the two nations/cultures/systems are.

Probably the biggest pushers of a cost competitive govt payer option are businesses, especially those who compete internationally. Detroit & other big employers are getting hammered by health costs.

[ERCougar]

Originally Posted by Ma'ake

Good points, all, which is why a pure Canadian style system won't fly. Incremental changes can be made, but people will have to adjust their expectations to a different equilibrium. There is no free lunch, and like you allude to, there are lifestyle problems that exist no matter the system.

I read somewhere the Canadian Supreme Court recently ruled it is permissible for providers to accept private payment, ie, patients could move up in line with extra $$ in hand. That alone tells you how far apart the two nations/cultures/systems are.

Probably the biggest pushers of a cost competitive govt payer option are businesses, especially those who compete internationally. Detroit & other big employers are getting hammered by health costs.

Agreed. I'm comforted by the fact that there are very smart people working on this whole issue and that every plan that has been seriously proposed seems to be more incremental than radical. I hope Americans have enough patience to see this occur; I do have to say that I'm nervous about a Democratic president and congress with a very strong mandate.

One issue that I see being ignored is the socioeconomic differences between us and Europe (or Canada). The poor obviously have worse healthcare outcomes, and I'm not at all convinced that it's entirely an access to care problem. African-Americans also have a higher prevalence of both hypertension and diabetes, even after controlling for socioeconomic status. These are very expensive diseases, probably the most expensive out there, if you include the cardiovascular and renal complications. Europe has a lower proportion of both poor and AA's, and that must play a role in lower costs and better outcomes.

[CardiacCoug]

Originally Posted by ERCougar

I don't think the scenario he paints is totally outside the realm of possibility. I'd be curious to see how Canada and Europe handle stenting; it's outside my field, so I don't know. There is good evidence to suggest that stenting isn't any more effective than medical therapy (except in the case of an MI). However, once you're already in and doing the angiogram, it seems kind of silly not to stent. I guess it depends on how much cost stenting adds to the angiogram. Any idea on this CC?

This is outside my field, so I don't know how Canada handles stents; I suspect CC knows, however. In emergency medicine, there is a fair amount of rationing that goes on when compared to here. Some of that's a good thing, cost-wise (and care-wise); we should be doing FAR fewer CT's than we are, for example. However, doctors don't face nearly the same malpractice threat. Anyway, knowing how things are done in Canada in emergency medicine, it wouldn't surprise me at all if they stopped stenting asymptomatic blockages in Canada.

I wish tooblue was right, but Medicare could absolutely start limiting coverage for elective angioplasty/stenting. It wouldn't surprise me at all.

Canada limits outpatient angioplasty/stenting by way of long wait times for stress tests and angiography along with limited facilities for primary PCI -- they use a lot of thrombolytics instead and just let people go ahead and have their heart attacks.

And while outpatient, elective stenting is superior to medications alone for relieving angina, it has not been shown to prevent MIs or prevent death. So it's a prime target for Medicare cuts. I wish this was just "fear-mongoring" [sic].

[tooblue]

Originally Posted by CardiacCoug

I wish tooblue was right, but Medicare could absolutely start limiting coverage for elective angioplasty/stenting. It wouldn't surprise me at all.

Canada limits outpatient angioplasty/stenting by way of long wait times for stress tests and angiography along with limited facilities for primary PCI -- they use a lot of thrombolytics instead and just let people go ahead and have their heart attacks.

And while outpatient, elective stenting is superior to medications alone for relieving angina, it has not been shown to prevent MIs or prevent death. So it's a prime target for Medicare cuts. I wish this was just "fear-mongoring" [sic].

You have presented a Red Herring with the express purpose of escalating fear ... fear of the unknowns ... I am certain many physicians would argue till blue in the face with your contentions about this particular treatment. I repeat: this PARTICULAR treatment.

Do you really believe that doctors in Canada are so indifferent, so hamstrung that they willingly LET people at highest risk of a heart attack simply have them!

By the way, not to burst your little bubble but I have a very good friend who I drove to the hospital with the exact condition and guess what he got the stenting and he isn't even high risk!

[CardiacCoug]

Originally Posted by tooblue

You have presented a Red Herring with the express purpose of escalating fear ... fear of the unknowns ... I am certain many physicians would argue till blue in the face with your contentions about this particular treatment. I repeat: this PARTICULAR treatment.

Do you really believe that doctors in Canada are so indifferent, so hamstrung that they willingly LET people at highest risk of a heart attack simply have them!

By the way, not to burst your little bubble but I have a very good friend who I drove to the hospital with the exact condition and guess what he got the stenting and he isn't even high risk!

I'm glad your friend got treated, but since his was an emergency procedure for which you took him to the hospital, he's in a different class. It's the outpatient, elective stenting that could be denied in the future.

The last study I saw that compared practice patterns in Canada versus the US showed that around 70% of US patients who were having heart attacks underwent angiography while only 35% of Canadian patients who were having heart attacks underwent angiography. 31% of Americans had their coronary artery opened or bypassed while only 12% of Canadians had the artery opened or bypassed. This is an old study (1993), but I think the general difference in practice pattern still holds, although I would hope doctors in both countries are more aggressive with performing angiography and interventions these days since there is much more proof that it works.

http://content.nejm.org/cgi/content/full/328/11/779

Why would Canada encourage expensive procedures to keep patients alive when keeping patients alive will just cost the system more money? It's just not economical. There is no incentive to make expensive procedures available in a socialized health care system.

[ERCougar]

Originally Posted by CardiacCoug

I'm glad your friend got treated, but since his was an emergency procedure for which you took him to the hospital, he's in a different class. It's the outpatient, elective stenting that could be denied in the future.

The last study I saw that compared practice patterns in Canada versus the US showed that around 70% of US patients who were having heart attacks underwent angiography while only 35% of Canadian patients who were having heart attacks underwent angiography. 31% of Americans had their coronary artery opened or bypassed while only 12% of Canadians had the artery opened or bypassed. This is an old study (1993), but I think the general difference in practice pattern still holds, although I would hope doctors in both countries are more aggressive with performing angiography and interventions these days since there is much more proof that it works.

http://content.nejm.org/cgi/content/full/328/11/779

Why would Canada encourage expensive procedures to keep patients alive when keeping patients alive will just cost the system more money? It's just not economical. There is no incentive to make expensive procedures available in a socialized health care system.

Just to play devil's advocate...
Don't you think we stent too many people? I've seen several recent studies that have shown medical therapy to be equivalent to stenting in both prevention of MI AND angina. If I recall, they can show a difference early, but at a year, the two are equivalent (and medical therapy is obviously much cheaper). I'll pull the studies if I get some time.

The problem I see is with the patient who's already in the cath lab for an angiogram and a blockage is found. While you're there, you might as well stent.

But yeah, overall, I am with CC on this one. Canada does achieve some savings by making access to certain expensive procedures more difficult. For CC, it's stenting; for my field, it's CT scanners.

[ERCougar]

Here's the study I was thinking about:
http://content.nejm.org/cgi/content/full/359/7/677

Essentially, a difference between the treatments that dwindles slowly until even at three years.

I'm not arguing for no more stents, but we certainly could cut back a little.