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Aidan

Kudos to Gladwell for having the integrity to admit that you were mistaken - I wish that more commentators were prepared to do so!

I have to say that I wasn't impressed by the arguments he employed in the 2000 piece, nor by the tenor of the exchanges with Gopnik, who clearly knew a great deal about what he was talking about. From what I've read of Gladwell's more recent writings, I seem to detect a real maturation in apporoach.

pwb

Just want to clear up that is was "JorgXMckie" not me, "pwb", who made those comments. The design of this commenting system makes it confusing who is attached to the comments. The name of the commenter is at the bottom, not the top.

But I will say that I find this statement to be false: "Canada's similar quality is delivered for 45% less $$ per person."

First, my experience is that US care is better in general and much better in many respects. Further, the US leadership in R&D provides somewhat of a subsidy for other countries.

Charlie (Colorado)

As I was saying, w.r.t. quality of care, before evaluating the cost vs quality question, I'd like to see what the quality measures are. But the notion that the quality is Canada is even acceptable seems to be sort of hard to credit, considering that the Canadian Supreme Court has found judicially that it's not.

http://www.nytimes.com/2006/02/26/international/americas/26canada.html?_r=1&oref=slogin

The Times article also notes that the *goals* being set by the Canadian health ministry are "four weeks for radiation therapy for cancer patients beginning when doctors consider them ready for treatment and 26 weeks for hip replacements."

Note, riley, that isn't the Fraser Institute; that the NY Times reporting the Canadian Health Ministry's goals for *improved* service. They sound pretty consistent with the Fraser study, at least presuming that the goals for improvement are meant to actually be better than the current conditions.

Again, anecdotally, I've lived in Toronto, and London ON, and attended Duke Medical School in North Carolina. (I'm not an MD, I was in a PhD program.) My cousine in Toronto had a GYN emergency, major haemorrhage, and was treated in the emergency room with packing and progesterone, and given an emergency GYN appointment --- in six weeks. In Durham NC, she would have seen a GYN before she took her feet out of the stirrups, or at worst the next morning.

As noted above, Canada uses its monopoly power to force drug prices down, and also makes a number of things (like codeine) over the counter that would be by prescription in the US. The effect is to transfer costs from Canadian consumers to US consumers; not a bad plan for the Canadians, but unlikely to help the US.

It's hard for a non-specialist to evaluate this stuff, but at least on this information, the notion that Canada is sustaining something like US-quality health care seems pretty questionable.

Mary

Well, if we're talking Toronto gynecological anecdotes: in December 2005 I had an urgent GYN issue -- not an emergency, but not something I wanted to delay. My gynecologist was out of town, so I looked in the Yellow Pages, phoned three offices, and was booked with another doctor within 2 days. I got excellent care in that office and a prescription that worked for me.

In January 2006, after several years of using just the local medical clinic for general medical issues after my family doctor retired, I decided to do the sensible thing and get my own GP again. I went to the web site for the College of Physicians and Surgeons and checked their database. Despite all the scare stories about how hard it is to find a GP in Toronto, I found several doctors taking new patients who fit my criteria (good location between work and home, affiliated with a hospital that was also easy to get to, and about 10-15 years out of medical school.) I called my first choice and had an appointment within 5 days for a general checkup and found him sympatico and knowledgable.

Brad Hurley

I don't think the Canadian healthcare system itself is failing, I think there are two primary reasons for the crisis (and there really is a crisis): 1) Canada's population is a tenth of that of the United States, and that may not be enough to support an adequately functioning state-of-the art public healthcare system 2) the proximity of the United States, where Canadian doctors can make a lot more money and deal with somewhat less red tape, plus the population issue mentioned in poiiint number 1, means that we have a shortage of health care providers.

Before I moved to Canada I thought the talk of a healthcare crisis was just a right-wing fairy tale, but in fact things are pretty bad, at least in the province of Québec where I live. You can't get a family doctor in Montréal; they all stopped accepting new patients many years ago, and my girlfriend had to wait three months just to get a routine x-ray and six months to see a specialist. If you get sick you go to a CLSC (clinic) or the emergency room; you never see the same doctor twice and the waits can be interminable.

But I still think the system itself is good in concept, it's just that there isn't enough money, and there aren't enough doctors and hospitals.

pwb

I don't see how people can make statements like this without laughting: "But I still think the system itself is good in concept, it's just that there isn't enough money, and there aren't enough doctors and hospitals."

Dave Lyon

I have lived in Canada and have experience with the health care delivery system there. For the most part, I have been impressed. However, I do believe my mother could have died if we had not really "pushed the bureaucracy" to reschedule her surgery.

I have experienced employer funded health care for many years - mostly availing of HMOs. Back in the 80s, I would go to my HMO office and visit a chiropractor. Those days are long gone as are the days of HMOs paying for 20 chiropractic visits. I prefer to not even visit the doctor's office even though I belong to a very good medical group (St. Jude's). It takes too long to get an appointment and you get the sense of being rushed during the visit. I will say the care is still decent but I wish alternative healthcare such as chiropractic were covered.

Nearly half of all Americans are taking at least one prescription drug (http://www.cdc.gov/nchs/pressroom/04news/hus04.htm). Obesity is on the increase. And in my opinion, I really don't think you can solve the health care insurance issue without first changing the way healthcare is used. Our culture has evolved into one where people eat on the run, work insane hours, drive in choking traffic to jobs far away, live in cookie cutter houses packed into sterile neighborhoods, eat tainted and overly processed food, don't exercise, and drive almost everywhere. Is it any wonder why so many are taking prescription drugs? Are we merely "medically treating" our poor lifestyles rather than encouraging healthy living? The drug companies are publicly traded, profit oriented companies. Think about that the next time you visit a doctor and he prescribes you a drug after talking with you for 15 minutes. The drug companies' warnings of side effects indicate that there are real safety issues with many drugs. Wouldn't it be better to change the way people think about their health and reduce their dependency on the medical industry?

michael j knight

you are correct. employer paid health care is crazy. individuals must take ownership. hsa's create ownership.and reform the sysytem so i can buy my insurance outside my state. competition solves many problems.

anthony baxter

Last time I looked, the US Veteran's Administration provided a very nice example to counter the traditional "governments can't run things" argument.

In Australia, we have both public (Medicare) and private health insurance. The administration and profit overheads make the private system far far less efficient (I can't find the numbers off the top of my head, but the difference was utterly startling).

One thing not mentioned enough is the notion of prevention. If someone can't afford to see a doctor for a minor complaint, it stands the risk of turning into a major complaint. This then can lead to a visit to the emergency room.

Speaking as an Australian, the US healthcare system is one very important reason that I don't plan to move to the US.

Gary Farber

If I might be so bold, here is a link you may or may not wind up finding useful. Goodness knows I did when I started blogging four and a half years ago, being a complete HTML illiterate, which I pretty much still am today, having learned only a couple of handfuls of tags.

But that list lets me look up the basic ones that I don't have stuck in my head.

Particularly useful is the simple way of embedding a link. Just scroll down to "Link Something."

To embedd a link, just do like so: [SUBSEQUENTLY EDITED OUT TO ALLOW POSTING]

Nice to see you blogging; I've greatly enjoyed and admired your work for years. I hope you don't find dealing with, or just reading, your comments too overwhelming or too much of a time-suck, but that you'll otherwise be able to keep up your blog with some vague frequency and without losing interest, and, of course, without it getting in the way of your for-$ work.

Revision: Ah. Your software is killing HTML. Well. Okay, trying the hard way:
[SUBSEQUENTLY EDITED OUT TO ALLOW POSTING]

To embed a link, on all but the rare sites that ban it:

The visibly linked word (s) go in between the "><"

It's an awful lot less ugly than having naked URLS, which, after all, can go on for many dozens of characters.

Second revision. Cripes, not only is your site killing working HTML, it's eliminating even simple angle brackets, and everything in them. Well, okay, just go to the link I gave, and scroll to "Link Something," like I said. If you're interested. If not, not, of course.

Gary Farber

Testing if just a non-embedded link will work here:
http://werbach.com/barebones/barebones.html

Lieutenant Breakfast

out-patient medicine in the US is so broken, such a trillion dollar
titanic, that fiddling around with
its economics is just moving the
deck chairs for a better view of
more disaster ahead
(David Bryson,MD Yale '63)

Gayle Irwin

One thing missing in all of the questions and discussions regarding the models in US vs. Canada, is what do we mean by wait times, and for whom?

In Canada, the wait times are universal and not meted out according to who can pay: i.e although they vary from region to region and from procedure to procedure, the wait times are the same for people of every income bracket, no one can queue jump simply because they have money).

If you want a hip replacement,and it is not an emergency, you are put in line.

Now, we can argue over how long we, as a society, want to wait for a non-manditory hip replacement and come up with some formula to determine acceptible wait times for optional procedures.(That is what the recent court decisions up here were about.) But to say that the American system means you can get these procedures as soon as you want, is to ignore the fact that only those who can afford to pay for that replacement can get it whenever they want, and the many many unisured, can not get a replacement at all.

A similar point can be made for the "quality" of care measures mentioned above. Under a user-pay and purely private industry delivered system, the user who can pay the most will get the best care. Under a universal/socialized system,the quality of care is not attached to the amount of money you have. Such are the trade-offs... but to say the Canadian system is somehow broken or less than the American system because of wait times or user-quality is a major red-herring unless you factor in how many people are left out of the waiting lists and the medical system altogether down there as part of the equation.

And, by the way, my mother who was 68 at the time, also received her hip replacement the next day, after falling and breaking her hip... furthermore, as a Canadian in the Canadian system, she was not asked to have to pay anything at all for it--which, given that she is living on less than $1500/month pension and not even owning a house after 30 years of working her butt off as a nurse, she likely would have had a hard time affording. (i.e. It is the optional procedures that are wait listed, and even they don't end up costing anything out of pocket, at least in her province--a couple of the provinces have instituted a $300-1100 annual fee for their medicare programs in order to offset the rising costs of expensive medical procedures.)

In sum: before all you conservatives down there start quoting numbers about how quickly you guys get your hip replacements, or how quickly you get in to see specialists, you might want to factor in the fact that those benefits are the result of selectively weeding out the poor who can't afford to pay as much as you. Until you add them back into the equation, your statistics are not valid.

S. R. Ponamgi

I believe that one of the important requirements for the smooth and efficient working of any service (like healthcare) is competent and devoted workers.

In my thirty eight plus years in USA I have come across such workers in the healthcare system only occasionally. It seems to me that this is has a lot to do with the failure of the US healthcare system.

S. Rao Ponamgi

Ganesh S.

Except that in the case of public transportation, we, as a culture, seem to have no problem with the jobless taking subways all over the place while others drive automobiles that range in value from Ford Pintos to Ferraris. In the case of health care, everybody demands (and rightly so) the right to the best possible health care with the best available technology regardess of their ability to pay. Consequently, smelly, urine-stained subway seats are not acceptable in the health care industry. Single payer health care systems are too inefficient to possibly fund this expected health care product. The under-funding problem is inevitable in any single-payer sytem. As many dissenters have already pointed out, the current US system may not be the best possible one, but it is certainly better than Canada's.

jean z

first of all - sorry, pwb, i did indeed mistake you for someone else.

second: "I believe Canada is now in the first stage, imprisoning anyone offering private health care" - ben, can you provide a source for that?

Nils S

Anecdotal evidence is a dime a dozen, but: I'm 29, had a very strange disease as a child for which I was briefly hospitalized, and currently freelance for a living.

I have no health insurance because I have been priced out by insurers. Though I've received no medication or treatment for my oddball illness since the 8th grade, it has left a paper trail that will add in a factor of at least 3 to any offer an insurer might make me.

I couldn't barter my way into a normally-priced insurance plan even if I promised to waive any future services related to my old illness. I am, as they say in the business, SOL. Unless I'd like to pay 800 a month to blue cross.

So I'm left with only 2 viable options: change careers or cross my fingers.

At the moment, I brush the hell out of my teeth and hold my breath when I drive past a graveyard.

Canadian

Do evil socialist countries hold down the price of drugs with price controls?

Or does the US force up the price of drugs with over-protective patent legislation?

Jason

Brad FINALLY gets to the point that nearly everyone misses and that is a key factor in helping the Canadian system remain a "success" - namely that it is right next door to the US!

Let me say that there is no question that the US system of health care delivery/payment is screwed up! And as a firm believer in free markets and captalism I do not see any easy answers. An article on Slate recently about a Federal Reserve type of modified single payer system actually sounded interesting but I digress.....

Canada specifically as a single payer system is largely a "free rider" which is what Brad touched upon. Americans buy perscription drugs in Canada because the price is lower. Why is it lower? Partially because Canada controls the price and they can do that because we in America effectively subsidize the research and development cost of those drugs by paying a lot more.

Wealthy and/or desperate Canadians can come to the US to avoid lines or to get treatment(s) that Canada wont cover - thus relieving pressure on the Canadian system. etc etc.

To evaluate the 'success' or 'failure' of the Canadian model without taking into consideration the fact that the largest 'suppply' of the world's most advanced healthcare is right next door takes the "blink" concept a little too far. To torture the analogy further, Canada has a subway NOT just for people with a job but for everyone. However, they ALSO have a bullet train one block away that goes the same route as the subway does. When the subway is crowded and you can afford it, you can ride the train.

r

Mr. Gladwell,

How can the benefits of free-market medicine (innovations in "heroic" procedures and broader access to CATscans, MRI's, etc) be implemented into a Universal Health Plan?

I see how going from 60% - 65% helps with the MRI's and CATscans but how can the incentives for innovation be acheived?

On a side-note (like you really read the comments at this point) - I'm guessing you didn't expect 100 comments per post. Bittersweet I'm sure.

Thanks,


R

Matt Williams

What about the problem of innovation? Would we have developed cholesterol-lowering drugs (to take one example) if not for the U.S. market?

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just me

In response to MT's comment:

MT writes that
"The buck stops at the employer in the law, I guess, only because it hasn't discovered how to reach the government, which I guess would be an even more efficient cost distributor."

Yes, government would be "even more efficient." In fact, let's have them just run everything, and oh what a paradise we'd have!

Think of all the inefficient homebuilding companies we have. If we had a Department of Construction -- maybe by expanding HUD, just like national health care could build on Medicare's efficient success -- we could all get homes as nice as those HUD projects.

Then, let's have the federal Dept. of Education take over all those inefficient private colleges.

Wow, the future will be great! I can't wait!

dad

Good Stuff !

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  • I'm a writer for the New Yorker magazine, and the author of four books, "The Tipping Point: How Little Things Make a Big Difference", "Blink: The Power of Thinking Without Thinking" and "Outliers: The Story of Success." My latest book, "What the Dog Saw" is a compilation of stories published in The New Yorker. I was born in England, and raised in southwestern Ontario in Canada. Now I live in New York City.

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