If I were an American, I'd be dead

I decided to wade into the U.S. health care debate recently by making a diary entry on DailyKos, calling it "If I were an American, I'd be dead". It's a personal account of my experience with Canada's healthcare system for the benefit of our American friends. I'm not going to re-post the whole thing here - just wander over and read at your leisure.

The best and the worst thing about making that post was reading the comments from Americans dealing with their health care system. I was particularly struck by the story of one woman who defended the title of my post against someone who accused me of hyperbole. As it turned out, River (who has her own diary) has, like me, experienced kidney failure. She's not much older than me, in about the same income bracket. Or at least she was before all this.

Unlike me, however, River lives in the U.S. So when she started experiencing symptoms, she didn't go to the doctor right away because of the cost of co-pays and the fear of being declined. And so while my condition was caught in time (barely) to restore my kidneys to full function, hers failed completely and irreparably. And while I now lead a happy, healthy normal life, she is facing a lifetime of dialysis. Which probably won't be as long as you'd think, because she's about to hit the lifetime cap on her husband's medical insurance, at which point (as I understand it) she will be put on Medicare, which will only cover 80% of her dialysis. Unfortunately, even 20% of the cost of treatment is far beyond her means, so at that point she figures she'll be checking into a hospice to wait to die.

As for a kidney transplant, forget it. Not unless she wins the lottery - even if she could find a donor, which is twice as unlikely there than in Canada.

The most painful part of my little dialogue with River was when I jokingly suggested that Canada should have a "medical refugee" class of immigrants. She responded by begging me to check into this for her. She had looked into immigrating to Canada, but apparently someone in her medical and financial condition is not exactly the kind of person our Immigration Ministry is looking for as a Canadian citizen right now. It broke my heart to tell her that I'd just made it up, and that our current government isn't even letting our own citizens back into the country, let alone some sick indigent from the Greatest Country in the World.

I thought about River last night while watching 'Meeting of the Minds' on CNBC. They were having a round table discussion about health care with a pretty broad spectrum of people - a health insurance rep, a Democratic Governor, a Republican Senator, a cancer survivor, an AMA spokesman, a health clinic owner, etc. I found myself yelling at the TV a few times, but in general it was pretty enlightening.

The show helped me understand something that I really didn't before, and that is why so many supporters and opponents of U.S. health care reform keep insisting that America has "the best heath care in the world". I always assumed that they were merely delusional, but I think I get it now. You see, they aren't talking about "best" as you or I might define it, as in "the best outcomes for the greatest number of people". What they're talking about is Medical Miracles.

When Americans extol the virtues of American health care, they talk about technology like MRIs and PET scans. They talk about the baby who received heart surgery in utero, or the woman with the exotic tumour that was excised with robotic lasers directed by a surgeon halfway across the country. They talk about extraordinary drugs that can treat AIDS and lower cholesterol and cure cancer and give you a hard on at age 90.

This is what they mean by "the best", and this is what they are afraid they're going to be losing if they bring in any form of public health care.

I can almost sympathize with that. Almost. But even aside from my instinct to question why an entire nation should suffer for the sake of the .5% of the population who might benefit from such treatments and can afford to make use of them - I have to wonder why such a trade-off should even occur, and why having a public health care option would grind such research to a halt.

The argument is that these technical and pharmacological innovations are only made possible by the huge profits reaped by the health care industry. Unfortunately, the application of capitalist incentives to medical research tends to favour the Prozacs and the Lap-Bands over the cancer drugs and the exotic surgeries. And of course they have to sell those drugs and procedures aggressively in order to profit from them, which means spending millions on those annoying direct-to-consumer ads so people will try to convince their doctors that they're sick and get them to sign off on drugs and treatments that they may or may not need.

There was a lot of talk about market incentives in this particular discussion - where they are now and where they should be. There was a surprising amount of consensus that the British system of paying doctors more when their patients quit smoking or have lower cholesterol puts the incentives in the right place, whereas the current system of giving doctors the financial incentive to prescribe as many unnecessary tests, procedures and drugs as they can think up without actually making their patients more healthy... not so much.

That sounds like the kind of thing that could help Canada's own health care system become more cost effective while improving outcomes. But for the Americans, I'm afraid most of the schemes and alternatives proposed by the health industry advocates amount to cosmetic surgery on a dying patient.

It's already apparent that razing the whole mess to the ground and starting fresh is neither feasible nor desirable. Their current system is just too firmly locked into everything from social security to union contracts to be simply done away with all at once. More's the pity. But that reality doesn't preclude an incremental transformation of the sort Obama is proposing.

For River's sake, I just hope those increments are big enough to lead them somewhere significantly better than the status quo. The stakes could not be higher.