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Oct 04 2011

Rationing, policy, and woo

I am a passionate believer in publicly-provided health care. Despite the narrative that seems to be fairly widespread among the Americans I speak to, public health care delivery is a much better model than for-profit care. Like any human system, it has its flaws that should be examined and improved upon. However, as both a method of caring for sick people and a method of controlling health care costs, public systems are the way to go.

The ‘dirty’ little ‘secret’ of health care is that demand will always outstrip supply. There are a nearly-infinite number of things that could qualify as ‘health care’, and we want all of them. As a result, we have to find where the limits are – where we are comfortable saying “if you want this, you’re on your own”. In the fights over health care reform in the U.S., this process got a dirty name for itself: rationing. Sounds scary, right? Your grandma needs a hip replacement, and some government fat-cat comes in and says “nope, sorry, all you are covered for is euthanasia!” Grandma gets wheeled into the back room against her will, and is put down like a stray dog. THANKS, OBAMA!

Of course the reality is that rationing happens in any health care system, including the American one. The difference is in how we ration. Canada and other publicly-funded systems ration by restricting the number of services you can get, but everybody gets something. Usually that something is fairly high-quality care, but occasionally it is sub-standard and people have to fight. That is an outrage, and there are many professionals who dedicate their lives to reducing the frequency of such occurrences. In the United States, rationing occurs by restricting the number of people who actually get anything. By restricting in this way, demand is essentially artificially reduced, which makes up for the (inevitable) shortcomings in supply. It should be noted that the HMO model, which was created specifically to alleviate this, actually incorporates both kinds of rationing, which sucks for pretty much everyone besides the wealthy.

So assuming we can agree that it is both unethical and impractical to reduce demand by striking people off the insurance rolls, we have to find other ways of controlling costs. One method of controlling costs is to ensure that only treatments that have a demonstrated record of effectiveness get funded. So we pay for morphine, but not for homeopathic preparations of nettles. We pay for surgeons, but not for faith healers. We pay for osteopaths, but not for chiropractic:

The provincial NDP says it would reinstate cost-shared chiropractic treatments if elected government, a move that would reverse a cut made by the Saskatchewan Party in the 2010 provincial budget. NDP Leader Dwain Lingenfelter said some people are now forced to forgo chiropractic appointments because they can’t afford to pay, and they end up seeking treatment at medical clinics or emergency rooms.

(snip)

[Saskatchewan health minister Don McMorris] said there hasn’t been evidence of clogged ERs because of lack of access to a chiropractor. The money the government saved by delisting chiropractic services was redirected into the health system, where priority areas include reducing surgical wait times and ensuring that the province has a proper complement of nurses, McMorris said.

A quick crash course in Canadian politics for our foreign friends: instead of states, Canada has provinces. Legislation makes health care both a federal and provincial responsibility – the feds are responsible for kicking in money, and the provinces control how it gets spent. In exchange, the provinces are required to meet certain standards of delivery. There is no direct analogue to the NDP (New Democrat Party) in the U.S.A. – think the left flank of the Democratic Party. Brits can compare them to the Lib Dems. Everyone else… I dunno, you can judge for yourself.

So the government of Saskatchewan has made the decision to withdraw funding from one type of service (a process known as ‘disinvestment’ in the literature) and reinvest it in other priority areas. This is generally considered good policy – every dollar you spend on X is money you can’t spend on Y, so find the mix of X and Y that has the greatest benefit for the population. Skeptics like myself are also particularly cheered by this policy because there is really no reliable evidence to suggest that chiropractic actually works:

Despite the widespread acceptance of chiropractic as a medical treatment, chiropractic is based on theories that have not been validated by modern science. Though some evidence exists to suggest that chiropractic may be effective in the treatment of musculoskeletal complaints such as low back pain, other research indicates that chiropractic may be no more effective than doing nothing.

While chiropractors commonly promote and practice manual therapy in the treatment of non-spinal ailments, it is important to note that the risks of chiropractic manipulation may be considerable, and currently no scientifically reliable study exist to show efficacy of such treatment in non-spinal conditions.

I live in British Columbia, which is one of the most woo-friendly provinces in the country (if not the most). The reason that this decision cheers me up falls into two main categories. First, it means that there is now precedent to support de-listing some of the more ridiculous things that are covered by our provincial health care plan. As a taxpayer, I am told by the media that I have the right to complain whenever a cent of my tax money goes to something I don’t like, but in this case it is going to fund something that is a waste of money at best, and potentially fatal at its worst. Second, the government is actively defending the decision rather than knuckling under the ire of the populace, and is actually reinvesting the money in places where it’s hard to attack them. This points a clear direction to policy-makers and government officials in other provinces of a way to effectively execute priority setting activities.

Health care is a dirty world full of compromises, human drama, and legitimate suffering even when things are handled well. I believe in evidence-based policy making, and am happy to put this one firmly in the ‘win’ column for Saskatchewan, and hopefully the whole country by extension.

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18 comments

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  1. 1
    Retired Prodigy Bill

    Bravo for an example of Canadians framing the correct type of health care questions.

    While, as you point out, the USA version of health care uses both types of rationing, I’d like to also point out that the purpose of rationing in the USA differs from the Canadian model. The Canadian model seems to be based around the management of costs for the care of the populace. In the USA, the model is based around increasing profits: caring for the populace is secondary.

    The majority of USA citizens get their health insurance through the workplace. Workplaces that pay for part or all of their employees health benefits are quite often eager to increase corporate profits by subsidizing cheaper coverage. And insurance companies, I assure you, are dedicated to the proposition that denying claims or setting up barriers to claims is a good, good thing.

    I hypothesize that those two goals are a form of woo: healthy workers are, I suspect, more productive, as are workers who are not stressed out over health care. And making preventative and maintenance care more attractive would, it seems to me, benefit the insurance companies in the long run. Short term profit seeking seems ill-advised, regardless of the greater questions about providing care for the populace.

    To all the people in the rest of the world who frame the discussion about health care around actual health care, you have my respect and envy.

  2. 2
    ralphwiggam

    Well Said.

  3. 3
    Greg Laden

    I live in Canada. When my daughter broke her arm 9 years ago the physician that we had to take her to for her followups was 45 miles away. I damaged my knee last year and once again, the clinic I was required to go to was totally on the other side of the metro area and about a 45 minute drive and appointments had to be made 6 weeks in advance. Getting an apointment for physical therapy took so long that the first stages of that therapy, which were very important it turns out, were totally skipped because I didn’t even know about them… and there’s a therapy clinic I can walk to from my house, but I ended up at one I had to drive to three towns away.

    For our son, he had an interesting grown on his foot when he was born (I’m pretty sure it’s his little brother) and the first available appointment with a qualified dermatologist was 90 days out.

    All of those health care services were excellent once they happened, but the waiting time was absurd.

    Oh, hold on a second. Did I say I live in Canada? My mistake… I live in Minnesota, which is known as The Health Care State. Silly me for making that mistake. But somehow when the average American hears those stories about Canada, they’re like “uhuh…see? canada. uhuh! we don’t want that! uh uh”

  4. 4
    Crommunist

    That’s a terrible experience, Greg. It frustrates me to no end to see stuff like that, because I live halfway between the two worlds – provision and consumption. Doctors are frustrated too when they can’t give their patients adequate care due to administrative hurdles and logistics.

    The good news is that there are practical solutions to many of these problems. All we have to do is find a way to generate the political will to institute some of these fixes.

  5. 5
    Enkidum

    Another Vancouverite here, also cheered by the Saskatchewan news. We have to make choices about what not to fund, and chiropractic seems a great place to start. I’d like to see a lot more money put into things like dental and prescription drugs, which seem to be the two big expenses for my family.

  6. 6
    Crommunist

    Dental is for sure a major burden on many families. B.C. already has one of the best prescription drug coverage schemes in the country (through PharmaCare), so I doubt there would be a lot of traction for making any more big leaps.

    I have my own suspicions about where the best place to invest money is, and I may someday explain why this is so in greater detail. In a nutshell, they are dramatically increasing mental health care infrastructure and changing the way we deliver primary care. Basically, fewer people in hospitals, more community resources. This won’t, unfortunately, have the immediate benefit to families that you’re probably looking for. You’d only see the benefit in terms of decreased waiting times, but eventually we’d be able to allocate the money we ‘save’ in the hospital sector to other resources (daycare, pediatrics, public health campaigns) that would directly benefit you.

  7. 7
    Enkidum

    Yeah, funding dental seems a no-brainer to me. Pus leaking out of your mouth is going to kill you just as dead as pus leaking out of other bits of you – in fact if my anecdata is correct, bad teeth were one of the main causes of death until relatively recently. So it should be a health issue, surely. But I guess it not being included has a lot to do with bureaucratic inertia, and the fact that dentists don’t go to medical school so historically they’ve been treated separately.

    And I don’t want to complain too much – I’m well aware that my coverage is leaps and bounds beyond 90% of the world. I think Canadians often understate how good some of our governmental services are.

  8. 8
    Crommunist

    Emergency dental care is covered. Most services that happen in hospital are covered. It’s just family dental that isn’t, which is unfortunate because good teeth probably make you much more likely to get hired to a good job (the Halo Effect and all that). I think the amount of money the government would have to spend to cover family dental for everyone is probably the bigger impediment – not to mention the fact that it’s not necessary for them to do so under the CHA.

  9. 9
    Tisha Irwin

    When health care “reform” was in the news a couple years ago, one of my co-workers declared that she didn’t want the gov’t deciding what medical care she got. I said “so you prefer an insurance company bureaucrat doing that instead?” She didn’t have any clue how to answer that.

    I don’t think many Americans realize just how many conflicts of interest there are in our system. But the goal for insurance companies is to provide as little care as they can legally get away with. That doesn’t make for good health care, in this doctor’s humble opinion.

  10. 10
    Mary P

    There is dental coverage for children in low income families. I am not sure what the terms of coverage are beyond basic checkups. The rest of us have to buy coverage. I discussed getting dental coverage with my dentist. Because I have good teeth and only go to the dentist once a year the insurance cost would be more than what I actually pay to the dentist – even with an occasional crown.

  11. 11
    julian

    Yay! Healthcare discussion.

    It never ceases to amaze me how paranoid my fellow Americans let themselves be. It should be obvious with any government funded agency you are going to have to ration (be it police, fire departments, construction of new roads…), prioritize and limit how you expand resources. It’s going to happen. Now there very well might be prejudice at work within the actual decision making process. That’s something that should be and needs to be taken seriously. But ‘wheeling grandma off to be put down?’

    Not only is that absurd, it ignores the reality of the system we’re putting in place. (we as in the voters) We’re the ones who’re falling in lockstep with anyone trying to block actual progress and believe any conspiracy story we’re fed.

    —————-

    Glad to see woo is getting slapped down somewhere at least.

  12. 12
    Crommunist

    It’s much harder to undo stupid than it is to do smart from the beginning. It is especially at times like this, where so many Americans are suffering both medically and economically because they cannot afford health care, that my sympathy runs deepest for my south-of-the-border cousins. Whenever the pundits talk about socialism being a failed idea, I want to slap them in the face with a hospital bill.

  13. 13
    Crommunist

    Yeah. I wonder how much it would cost to provide dental insurance for the population of a province. It wouldn’t be that hard to calculate. The thing is that very few people experience life-threatening dental conditions, and the kind of money it would require to provide insurance could be “better” (depending on who you ask) invested in life-threatening or debilitating conditions rather than something that is mostly cosmetic.

  14. 14
    Crommunist

    I was at a MEDICAL SCHOOL and couldn’t get an answer to that question. I don’t think Americans have very good information about how their own system works – that hasn’t been my experience at least.

  15. 15
    MCJB

    Yeah what irritates me the most about the healthcare system here in the states is that you can have government funded healthcare if you are what they call poverty level. But if you are right above that level (which doesn’t take much trust me. Roughly 11-12k/year American puts you above the need for food stamps and most other government help), but you really can’t afford insurance, and if for some reason you’re making that amount of money and you are offered benefits through your job, people generally don’t take it because then you won’t have enough money to live on. Unless you have kids, then you’re good to go in that regard.

  16. 16
    Ken

    I was wondering what you meant when you said you were “required” to go to a certain clinic. That sounds like insurance company rules. Although people complain a lot in Canada, the fact is that if you have an immediate problem you get quick and proper care. If you have a condition that is less urgent, you may wait for a specialist or procedure. If I want to see my doctor for something common, I can almost always get in the same day. And the wait time at my local hosital Emerg is rarely more than an hour or sometimes two. Last year when my wife conked her head, we were in, x-rayed, and out in one hour, free of charge (except parking, grrrrr…). And that was in a city of over 1 million.

    All the other first-world countries provide universal health care. It’s time for the United States to learn that sharing is good. Socialize your health care just like you do firefighting, schools, and roads. Imagine if they were all private!

  17. 17
    Crommunist

    I think Greg’s example was explained as fictitious in the end – it was actually an experience he had in the USA. The HMO model does indeed force people to go to certain clinics and hospitals in a way that the Canadian system doesn’t.

  18. 18
    abeille

    I am glad to hear that chiropractors are not being funded!

    As a massage therapist, some of the things that I get routinely asked is if I can recommend a “good chiropractor” and why don’t I get a job in a chiropractor’s office. (If I did, I could charge insurances!)

    BECAUSE IT IS WOO.

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