A major study of the way several health care systems deal with the chronically ill was printed in the medical journal Health Affairs in November. Aside from a brief notice in a recent Medical Post, it went almost entirely unreported in Canada -- yet Canadians helped pay for it; our country data were collected by the Health Council of Canada and by provincial agencies in Ontario and Quebec. In eight developed countries, similar large samples of "sicker adults" were quizzed on various aspects of their continuing care. The paper caught my attention partly because my genetic history of hypertension finally caught up with me in November and landed me in the hospital; depressingly, I now qualify as a "sicker adult." (Send chicken broth c/o this newspaper.) Other chronic conditions included in the samples included heart and lung disease, arthritis, diabetes, cancer and depression.
These repeat health care customers are naturally well-equipped to report on access, care co-ordination and medical error. Although Canadians were in the middle of the league table when it came to overall satisfaction with their health care, we fared shockingly badly in some respects -- in precisely the ones you might expect, actually, which perhaps explains why the study results were not covered more widely. Respondents were asked how long it took them to get in to see a doctor the last time they were sick. In Germany and the Netherlands, more than 50% were able to get treatment the same day. Canada's numbers were the worst of all: just 37% reported receiving care the same day or the next, and 34% had to wait six days or longer for primary care.
Chronically ill Canadians were also much more likely than those in other countries to visit the emergency room if they fell ill at night or on a weekend. (Apparently, in some places, they actually have other options.) Overall, 23% of the sicker Canadian adults had visited the ER in the past two years with conditions that would have been treatable by means of a regular doctor's appointment. The same figure was 19% in the U. S., 17% in Australia and under 10% in France, Germany, Holland, New Zealand and the U. K. Needless to say, Canadians also experienced the longest wait times for specialist care by an equally discouraging margin.
The numbers aren't all bad. Canadian doctors, for example, seem pretty well-trained at communicating with patients and preparing treatment plans for them. We are no better or worse than average in making sure that medical information follows the patient around, and that family physicians and specialists seeing the same patients are in touch. We are world leaders, with the U. K., in providing medical advice by telephone.
But overall the picture that emerges is that of a country which, as the authors state in their concluding discussion, "continues to face capacity restraints in both primary care and access to specialists." As usual, comparisons with the screwed-up American health care system are beside the point; down south you at least do get the quality of care you can afford. But we seem to be paying more than other peers for health care that is, on the whole, more tightly rationed.
It's usual here for a libertarian like myself to roll out the skein of familiar arguments about personal freedoms for doctors and patients. But if we're studied against the backdrop of non-American systems, it may actually be our high degree of patient choice and physician freedom that makes our system suboptimal. We tolerate what is, increasingly, warehouse-style care for the middle class in exchange for the freedom to choose our own physician and switch easily -- assuming we can find a physician at all. And we face capacity restraints partly because we have deliberately limited ability to order doctors to move to the countryside or work nights and weekends.
(British Columbia, for example, is facing a squabble over a directive from its college of physicians and surgeons that walk-in clinics who see a patient three times for the same complaint must take over full, formal responsibility for that patient's primary care. Doctors who chose walk-in careers as an alternative to becoming full-time family physicians -- because B. C. allowed them to -- are complaining, with some justice, that they've been subjected to a bait-and-switch.)
These fundamental libertarian considerations are important morally, and worth paying for. It's when we combine them with an ideology of equal (or equally compromised) access that we run into practical trouble. But on the other hand, we are relatively content with the expensive status quo, and one would have serious trouble, more than most laymen recognize, proving that health care rationing creates much harm. I sometimes wonder if the political class recognizes this, and prefers that we actively forget our memories of a more humane, efficient style of health care that once existed here -- a style that would reduce wait times and ostentatious ER abuse, but might not make much difference to outcomes.