The Incidental Economist Blog started talking about wait times this past week, and has several interesting posts on the topic here, here, and here. I won't reiterate them, they speak (well) for themselves. The bottom line is that we aren't really any great shakes with our wait times and access to care, we spend way too much time and money and use too much of our work force doing expensive procedures when we should be concentrating on primary care and reducing the need for all of those heroics. The US supply of physicians vs. specialists is inverted from high performing health systems where most doctors provide primary care.
Given this background, here's my take.
When I discuss health care reform with friends, families, colleagues, or in public, the two most pervasive myths about health care outside the US are that in every other country, care is inferior and rationing is accomplished by intolerable waiting times. As I endeavor to dispel these myths, I am invariably told an anecdote about a person who died in Canada or England awaiting some procedure or other.
Dispelling these myths is two-fold: first, pointing out the rationing that occurs in America either by private health insurers or by lack of wherewithal to afford services, and second, by pointing out that there are more health care systems than “ours” and “theirs.”
Given that an estimated 45,000 Americans are estimated to die every year due to lack of access to health care services , rationing in America is particularly troublesome, and oddly overlooked. There are many reasons for this, but mostly it is the lack of drama and, paradoxically, the pervasiveness of this experience, especially to those of us in health care. Anecdotes are powerful things, and so I have to always tell a few of my own to counter the horror stories they’ve heard about other countries. So, a few cases of my own: a man who puts off seeing a doctor (for what he knows is diabetes), ends up in the ICU critically ill, because he is trying to get on a health insurance plan and hopes he won’t be found out; a down-sized engineer with a year long persistent cough and weeks of coughing up blood, who waits until he is near death to come to the hospital because he can’t afford to see a doctor; and finally a young man with a seizure disorder admitted twice to the ICU for unremitting seizures in just a few months because his neurologist won’t see him because he’s been underemployed and couldn’t pay his last bill. Multiply my stories by nearly a million physicians in America and you see the magnitude and pervasiveness of the problem.
Beyond anecdotes, there is actual data, such as the Commonwealth Fund study showing that "U.S. patients reported relatively longer waiting times for doctor appointments when they were sick, but relatively shorter waiting times to be seen at the ER, see a specialist, and have elective surgery.” Additionally, Americans are less likely to have a regular doctor, less likely to get prescriptions filled, less likely to get follow-up care, less likely to keep a doctor long-term, and have a harder time getting taken care of nights and weekends. In another report, the Commonwealth Fund has shown the US ranks 19th out of 19 countries evaluated on preventing deaths that are amenable to adequate health care, an excellent measure of the overall performance of a country’s health care system.
That there is more than one country outside the US with a unique health system, might surprise some whose rhetoric suggests a vast wasteland of a series of Soviet style medical gulags. OECD data shows (Siciliani, 2003) that waiting times are a problem in some countries, but only about half of those in the OECD. The others are like the United States in lack of significant waiting times, but unlike us they manage to do this with their entire population covered, and at significantly lower costs.
Now, let's do a little thought experiment. Say you are in a country that has relatively high waiting times for elective procedures, say Canada (but not England so much any more!). Take one sixth of your population and deny them access to care because, oh, they don't deserve it. What do your waiting times look like now? Take another sixth or so, and tell them they have to choose among school, dental care, glasses, food OR preventive health care. Or even life saving health care. OK, now how are your queues?
Americans ration, all right. It is unbecoming, to say the least. It is leaving people to slowly die, to be more blunt. It is under the radar for most, but not for us, not for the millions of care givers and social workers and nurses and parents and children who have to bear witness.
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