A reader sent me this provocative piece on Canadian healthcare, written by someone who knows care on both sides of the border. It comes from the Campaign for America’s Future website. And it is, as advertised, a “myth-buster.” I look forward to Part II.

Mythbusting Canadian Health Care Part I                
By Sara Robinson                
February 4th, 2008

2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning — and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.

I’m both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I’m in a unique position to address the pros and cons of both systems first-hand. [my emphasis –mm] If we’re going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.

To that end, here’s the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they’re made of.

1. Canada’s health care system is "socialized medicine."

False. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that every doctor deals with one insurer, instead of 150. And that insurer is the provincial government, which is accountable to the legislature and the voters if the quality of coverage is allowed to slide.

The proper term for this is "single-payer insurance." In talking to Americans about it, the better phrase is "Medicare for all."

2. Doctors are hurt financially by single-payer health care.

True and False. Doctors in Canada do make less than their US counterparts. But they also have lower overhead, and usually much better working conditions. A few reasons for this:

First, as noted, they don’t have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.

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The newest issue of the medical journal Obstetrics and Gynecology contains a compelling study by R. Jeanne Ruiz of the University of Texas and colleagues. The team looked at 468 low-income pregnant Hispanic women to see how much levels of acculturation (measured by proficiency in English) affected premature birth. What they found is not what you might expect: those mothers who are better assimilated are more than four times as likely to give birth to a premature baby.

That’s right: Women who were born outside the U.S., had not completed high school, were not proficient in English, and had lived in the U.S. for fewer than 10 years were more likely to have higher levels of progesterone. (Researchers have found that a form of the hormone progesterone can reduce the rate of premature births).

This is pretty counter-intuitive—poor and poorly assimilated women with low levels of education are in one important respect healthier than their more Americanized peers. What gives?

While the article is primarily concerned with pointing the distinction rather than trying to explain it, the general message is clear: there’s something different about the way unassimilated low-income Hispanic women live their lives. The obvious distinction is diet and nutrition. I think it’s fair to say that the more someone is tied to his or her culture of origin, the more likely he or she is to consume that culture’s traditional diet.

Hispanics are a broad group, so it’s tough to pinpoint exactly what “less American” Hispanics eat that “more American” Latinos don’t. On the whole, however, the Hispanic diet is much heavier in grains, beans, and fresh fruits and vegetables than the typical American meal. And studies have actually shown that Spanish-speaking Hispanics stick closer to this diet than their English-speaking peers who are more like pick up American eating habits.

Guess who eats healthier?

In 2000, the Department of Agriculture studied diet and nutrition among Hispanics in the U.S. Rating diet quality on a “healthy diet index” drawn from government nutrition recommendations and the food pyramid, the authors found that less assimilated Spanish-speaking adults and children scored higher than their English-speaking counterparts (see table below). In other words, less acculturated Latinos eat better—mostly because they consume less fat and more fiber in their diets.

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Today, the New York Times reported on a “troubling new report from the Agency for Healthcare Research and Quality (AHRQ), which analyzed hundreds of studies in an effort to advise men about the best treatments for prostate cancer. The report compared the effectiveness and risks of eight prostate cancer treatments, ranging from prostate removal to radioactive implants to no treatment at all. None of the studies provided definitive answers. Surprisingly, no treatment emerged as superior to doing nothing at all. [my emphasis]

“When it comes to prostate cancer, we have much to learn about which treatments work best,” said agency director Carolyn M. Clancy. “Patients should be informed about the benefits and harms of treatment options.”

The Times went on to quote the agency saying “Considerable over-detection and over-treatment may exist.” 

I have written about this issue here  and here; Niko has written about it here.

I am not going to repeat what we have said in the past. But let me emphasize that the AHRQ looked at practically every treatment now being used:

“The agency review is based on analysis of 592 published articles of various treatment strategies. The studies looked at treatments that use rapid freezing and thawing (cryotherapy); minimally invasive surgery (laparoscopic or robotic-assisted radical prostatectomy); testicle removal or hormone therapy (androgen deprivation therapy); and high-intensity ultrasound or radiation therapy. The study also evaluated research on ‘watchful waiting,’’ which means monitoring the cancer and initiating treatment only if it appears the disease is progressing.”

The agency goes on to warn that “all active treatments cause health problems, primarily urinary incontinence, bowel problems and erectile dysfunction.”

Finally, the Times points out that while “one study has shown that men who choose surgery over watchful waiting are less likely to die or have their cancer spread, another study found  no difference in survival between surgery and watchful waiting.” Moreover—and this is important—“few patients in the study had cancer detected through P.S.A. tests. As a result, it’s not clear if the results are applicable to the majority of men diagnosed with the disease.”

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The worst thing that a journalist can do is to present opinion as fact—especially when talking about something important. To do it on Super Tuesday is particularly irresponsible.

Yet that is exactly what conservative columnist David Brooks has done in today’s New York Times.

Responding to what Paul Krugman wrote yesterday (see my post below, “But There Is A Difference Between Obama and Clinton on Healthcare”), Brooks attacks Hillary Clinton for insisting that if we want universal healthcare, we are going to have to ask everyone to get into the pool. Rich and poor, young and old, healthy and sick—everyone will need to contribute to the national healthcare fund by signing up for insurance. Otherwise, we won’t be able to afford the subsidies that low-income and working class families will need to enroll in the plan.  Hillary’s mandate is much like the mandate that we all contribute to Social Security or Medicare.

As Brooks sees it, the issue “is over whether to use government to coerce people into getting coverage. The Clintonites argue that without coercion, there will be free-riders on the system.”

In other words, the Clintonites are concerned that young, healthy people who earn too much to qualify for subsidies may not sign up—especially since, under healthcare reform, they will know that once they do get sick, insurers will be required to cover them and will not be allowed to charge them more than they charge everyone else. Thus, while older, sicker people pay into the pool, younger healthier people will get a “free ride”—until they need insurance.   

“They’ve got a point,” Brooks admits briefly, referring to Clinton’s position.  It’s really rather hard to argue with common sense. “But,” he adds, “there are serious health care economists on both sides of the issue.”

Who exactly does he have in mind?  Brooks doesn’t say.

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I love the Internet. I love convenience, and technology. The creation of new inequalities at a time of profound disparities in health care, however, isn’t my cup of tea. So I have mixed feelings about the fact that online medical consultations are gaining steam.

On the one hand, the pluses are obvious. As I’ve written in a previous post, Tom Delbanco from Harvard Medical School estimates that 50 percent of visits to the physician are unnecessary and could probably be dealt with online. Yet a measly eight percent of doctors use e-mail to communicate with patients, let alone set up their webcam to talk shop. That seems foolish.

But, Doubting Thomas that I am, I see some problems with the rise of Internet consultation. Ultimately it seems like another case of wrong-headed priorities. Once again, too much attention is paid to dispensable improvements that don’t address fundamental problems with our health care system. Enough with the bells and whistles already. 

Traditionally, the biggest obstacle to online consultation was the fact that insurance companies didn’t reimburse doctors for web-based work. But recently Aetna and Cigna, two of the nation’s biggest insurers, have agreed to reimburse doctors for online visits. Other big dogs in the insurance world are likely to follow suit soon.

With these changes, the anatomy of the web-doc industry is beginning to come into focus. For online consultation to be reimbursed by insurers, paperwork needs to be filled; for doctors to have a booming Internet practice, they need a strong online presence. To help with both of these matters, new companies have entered the fray, with cookie-cutter names like RelayHealth and Medem (“medicine” + “modem”; genius!).

The L.A. Times describes how these companies work:

To begin using these online services, patients visit a doctor’s website or go directly to one of the Internet companies that handle such services…Doctors are typically encouraged to respond to patients within a day; they receive an e-mail reminder if they haven’t, with a phone call on the second day. Prices can vary from $25 to $125, which patients pay with a credit card at the end of the session.

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Today, I talked to Bob Blendon, who is a professor of health policy and political analysis at Harvard’s Kennedy School of Government, about Super Tuesday’s multi-state primary contests and what they might mean for healthcare reform.

Blendon agrees with the consensus on the Democratic race. Hillary Clinton and Barack Obama are running nose to nose, but Blendon points out, if you take a closer look at the polls, you find an unusual contradiction.  Not only are the voters split between the candidates; there are very split, within themselves.

“When you ask about the issues, Clinton wins on almost every point, including healthcare,” Blendon reports.  But when you ask about character, likability, leadership, ability to inspire—Obama is the clear favorite.

“Usually, people can’t live with that much incongruence,” Blendon adds. “Once they decide who they like, then they decide that person is the best on the issues. Normally, people don’t like incongruence within themselves.”

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In the post above I quote Harvard professor of health policy and political analysis at Harvard’s Kennedy School of Government Bob Blendon as saying that voters perceive little difference between Obama and Clinton on healthcare reform. And I think he’s right. But that’s because most voters haven’t honed in on the fine points of their plans.

Those who have scrutinized the plans, and understand the economics of healthcare reform, see important differences—differences that could be deal-breakers.

In today’s New York Times, Princeton economist Paul Krugman argues that because Obama’s plan does not require everyone to sign up for insurance, it would be more expensive—and thus less likely to pass Congress. Without a mandate, Obama’s plan “would face the problem of healthy people who decide to take their chances or don’t sign up until they develop medical problems, thereby raising premiums for everyone else,” Krugman points out. He acknowledges that “Mr. Obama, contradicting his earlier assertions that affordability is the only bar to coverage, is now talking about penalizing those who delay signing up — but it’s not clear how this would work.”

Writing on The American Prospect today, economist Dean Baker from the Center for Economic and Policy Research responds to Krugman, saying that he knows how penalties would work:

“Obama has suggested that we can have a system of default enrollment, whereby people are signed up for a plan at their workplace.

“People would then have the option to say that they do not want insurance, so they are not being forced to buy it. However, they will then face a late enrollment penalty if they try to play the ‘healthy person’ game. When they do opt to join the system, at some future point, they will have to pay 50 percent more for their insurance, or some comparable penalty for trying to game the system. “

What Baker doesn’t say is what we will do with families who cannot afford to pay such stiff penalties when they finally decide they need insurance. Would we subsidize the penalties?

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Health Beat Blog is getting a new look. Some of you have asked for larger type, so we’ve re-designed the blog to make it more readable, while including a few extra features– including a link to our “Most Read Posts.”

We’re rolling out the new design on Monday, February 4. If something isn’t displaying property, please be sure to refresh your browser. In Internet Explorer, this is the button with green arrows to the right of the address bar (F5) and in Firefox, this is the blue arrow button to the left of the address bar (Ctrl+R).

Earlier this month, I wrote briefly on how the relationship between high cholesterol and heart disease is growing murkier than has been traditionally assumed. Today, by way of Gary Schwitzer’s Health News Blog, I came across a recent BusinessWeek article by John Carey that cracks this story wide open—in part by addressing an incredibly important, but often misunderstood and misused—statistic: the “number needed to treat.”

The succinctly titled piece, “Do Cholesterol Drugs Do Any Good?,” notes that “Americans are bombarded with the message from doctors, companies, and the media that high levels of bad cholesterol are the ticket to an early grave and must be brought down. According to these ubiquitous messages, statins [cholesterol-lowering drugs like Lipitor] “are the most potent weapons in that struggle.” Carey notes that Lipitor advertisements claim that the drug “reduces the risk of heart attack by 36 percent…in patients with multiple risk factors for heart disease.” Sounds pretty effective, right?

Hold the phone—there’s more to that number than meets the eye. Carey notes that the 36 percent is accompanied by an asterisk stating that “in a large clinical study, 3 percent [or three out of every hundred] of patients taking a sugar pill or placebo had a heart attack compared to 2 percent [or two out of every hundred] of patients taking Lipitor.”

Now, Pfizer’s number isn’t an outright lie. Pfizer, Lipitor’s manufacturer, says its potion reduces risk by  36 percent because the difference between two patients getting a heart attack on Lipitor and three patients getting a heart attack on placebos is one patient—or about a third the number of heart attacks that would have happened without Lipitor.

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Do we know enough about measuring the quality of healthcare to pick out the best doctors?

When I asked Don Berwick that question last week, he spread his hands: “You’re looking at the cream of crap. The system is so broken,” he explained, “that even the high performers are far away from optimal performance.  Most measures of quality are simply measuring the system that the doctor is trapped in, not the doctor himself.”

Who is Don Berwick, and why is he saying such terrible things about our healthcare system?

Dr. Donald Berwick, President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI), is widely recognized as one of the world’s most respected experts on healthcare quality. In 2005, Modern Healthcare, a leading industry publication, named Berwick the third most powerful person in American medicine.  In contrast to others on Modern Healthcare’s list, Berwick “is not powerful because of the position he holds,” noted Boston surgeon and author Atul Gawande. (Former Secretary of Health and Human Services Tommy Thompson ranked no. 1 on the list while Thomas Scully, the head of Medicare and Medicaid Services, captured the second spot).  “Berwick is powerful,” Gawande explained, “because of how he thinks.”

When Berwick thinks about the U.S. healthcare system, the word he uses is “bloated.” There’s a myth that American healthcare is the best in the world,” he noted at a Families USA conference last week. “It’s not,” he said bluntly. “It’s not even close.”

“It’s thought to be the best because we have the most healthcare,” Berwick told his audience. But in fact, although we spend twice as much as the average developed country providing more care than any other nation in the world “40 percent of the care that Americans actually need is not received.” Why?

“Cost is the barrier.”

“Here is a question I often ask my students,” added Berwick, who is a Professor of Pediatrics at Harvard. “When you meet a new patient, what is the one test that you could do that would tell you how long that patient is likely to live?

Typically, students answer: “Ask them if they smoke,” or “Test their blood sugar.”

“No,” says Berwick, “Just look at the color of their skin.”

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