Sunday, July 26, 2009

Health Care Reform

I honestly don't know how to advise Americans as they struggle with health care insurance reform, which has somehow been combined, by the Obama Administration, with health care reform.

We lived in the U.S. for six years. While there, our daughter was born with severe disabilities, most of which did not really require hospital care specifically after her first year. But she did require home care, specialized respiratory and feeding equipment, and support from specialists. As a rule, we were either impressed or dazzled at the quality of care she received. I had insurance through my college teaching jobs, and every year or two years there would be some suspense: what is the plan going to be this time? Are our doctors in the network? What is the penalty for going out of the network? (For a while the neurologist agreed to accept the out-of-network fees, instead of his usual fees).

We were generally treated like valued customers--people wanted our business. One respiratory supply company became big and impersonal--the phone was answered by someone who really didn't know the products. Voila: the respiratory therapists--the real brains of the company--formed their own company, and they would come out with a van to make sure everything was as it should be. Specialists and others indicated that they took a special interest in our daughter, and in us. We probably hit the golden age of homecare nursing. Reagan (of all people) had tried to ensure that children could get nursing at home if the only alternative was much more expensive care in hospital. Some federal funding was available through Medicaid, but whether you really got the service depended on what state you lived in. We were lucky to be in Minnesota. After we left, we learned that the hospital supplying us with nurses had been forced to cut back on service--so things may have gone downhill if we had stayed.

In New Brunswick there were fewer services, and the province wouldn't issue us the upgraded health card we needed until we had been there a year. Fortunately, we had been given, yes given, a bunch of respiratory supplies as we left the U.S. Still, the providers we encountered in the Maritimes of Canada were very good.

In Southern Ontario, we had some odd experiences. All family doctors complain that they're not paid enough. On the one occasion when Katie was hospitalized locally, our family doc took the trouble to say he would no longer be seeing her--apparently there was no way for him to be paid enough for routine visits to such a complicated case. We've had other family docs who have gone out of the business. In that same hospital stay, all the nurses on the ward acted as though they were pissed off at us for even bringing our daughter there. Should we have taken her to Sick Kids in Toronto? Possibly, but it was still a bizarre response from a group of nurses. It had a Stepford Wives feel--obviously nurses coming on shift, who had never met us, had been briefed by the time they saw Katie and us--and they were already scowling at us. Very weird. This was the hospital now known as Southlake.

So I end up with the conventional view: it is great to have good insurance in the U.S., but nerve-wracking to have to pay for it, deal with limitations and restrictions, etc. (Some Americans advised: apply for a job without stating there are any medical issues in your family; submit bills, they might just get paid; if you get caught and get fired, start again). In catastrophic cases, which our daughter was not, you can go through the lifetime maximum of insurance coverage--and then what? But with good insurance, you can get excellent care, with the feeling that you can be in contact with some of the top specialists in the world.

In Canada, specialists who are probably just as good are around somewhere, but you are more likely to be dealing with crabby, discontented people. Some caregivers show little respect for patients, perhaps because patients don't really pay. (Aristotle says common areas aren't those that everyone cares for; they are those that no one cares for). We dread going to the ER, but one colleague says his family had an excellent experience at the hospital, including the ER, in Peterborough--a little ways from Toronto, like Newmarket where I live, but maybe not quite a suburb?

Outcomes, Canada vs. the U.S.? Not very different. No doubt some people suffer or even die while waiting in Canada, but that can happen anywhere. Americans with insurance are tested a lot more, but the actual benefits of testing are questionable. For every one person who 1) has something treatable and 2)gets it properly treated thanks to the testing, there are probably six to 10 who get false negatives or false positives, and either let symptoms go untreated or get unnecessary treatments which themselves are potentially harmful. It's very American to put so much faith in tests. Of course if you are that one person who benefits, the whole system seems great to you.

In the Western world, advances are now of a kind that are expensive, and benefit few people. (Ht Kaus, and see Reynolds on his own family). Who will pay for these things? The harsh fact, and harsh question, are usually obscured by means of bullshit, now taken up by Obama, to the effect that there is a lot of money to be saved by way of exercise and weight loss, or by money-saving changes in pills and procedures. There might be some savings, in a way that is never admitted, in that those who lose weight die younger. The running magazines all think running will both improve your health and help you live longer. We'll see.

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