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March 23, 2009

Inequities in socialized health care

By Danny Huddleston
The goal of socialized health care is not to provide exceptional health care to the few but to provide "cost-effective" health care to everyone. In theory this may be a worthy goal, but how does it work in the real world?

The UK's National Health Service was created in 1948 and you would think by now they would have their act together but as any regular reader of this website knows, no one can outdo the British when it comes to health care horror stories. Here are just a few examples:


The Canadian system may be slightly better than the NHS in the UK. Of course it's lucky for Canada that the excellent health facilities in the U.S. are just across the border and act as a safety valve. As Dr. Alastair S.E. Younger explains in this article at aaos.org:

Without a private system, Canadian patients have nowhere to turn, which is why so many seek care in the United States. In fact, the United States is the private arm of the Canadian healthcare system. The Cleveland Clinic, for example, has an office in Toronto.

And from Lisa Priest at globeandmail.com:

More than 400 Canadians in the full throes of a heart attack or other cardiac emergency have been sent to the United States because no hospital can provide the lifesaving care they require here.

Most of the heart patients who have been sent south since 2003 typically show up in Ontario hospitals, where they are given clot-busting drugs. If those drugs fail to open their clogged arteries, the scramble to locate angioplasty in the United States begins.

"They rushed me over to Detroit, did the whole closing of the tunnel," said Eric Bialkowski, 47, of the heart attack he had on March 14, 2007, in Windsor, Ont. "It was like Disneyworld customer service."

Stories like this show that government run health care can be hazardous to your health. But even with all these problems you would think there would be one area where it would work. And that would be the elimination of inequities between the rich and the poor.

Well, guess what? They can't even do that right. The Canadians have been trying to eliminate inequities in health care for five years now and the situation is worse than before.

The results of a five year study from the Institute for Clinical Evaluative Sciences (ICES) has recently been published. At the beginning of the study the affluent citizens of Ontario were 25% more likely to receive a MRI than the poorer citizens.

After the study began the province put in place a strategy to increase access to MRI scans and reduce wait times. In a little over three years $118 million was spent and the number of scans performed doubled.

There was only one problem, now the wealthier Ontarians are 38% more likely to get a MRI scan than their less well-to-do counterparts.

The health care inequities are markedly worse!

Here is an excerpt of the report on the ICES study from the Canadian Health Reference Guide:

Toronto, March 4, 2009 - Ontario wait times for Magnetic Resonance Imaging (MRI) have improved since the provincial government's Wait Time Strategy began in 2004. But a study out of the Institute for Clinical Evaluative Sciences (ICES) has found wealthy Ontarians are now 38 per cent more likely to receive MRI scans than their poorer counterparts.

The study of 1,356,750 outpatient MRI scans done in Ontario between April 1, 2002 and March 31, 2007 found:

* At the beginning of the study, before Ontario's Wait Times Strategy began, a gap in access to MRI scans based on income existed. Patients living in the richest one-fifth of Ontario neighbourhoods were 25 per cent more likely to receive MRI scans than those living in the poorest one-fifth of neighbourhoods.
* During the next five years, during which approximately $118-million in Wait Times spending was injected for MRI services between November 2004 and March 2008, the annual number of MRI scans performed in Ontario doubled.
* However, the increase in MRI use over the five-year period was largest for those in the wealthiest Ontario neighbourhoods, so that the gap in access to MRI between rich and poor widened. Patients living in the richest neighbourhoods are now 38% more likely to receive MRI scans than those in the poorest neighbourhoods.
* So, while Ontario's Wait Times Strategy has improved access to MRI, the findings suggest the improvements in access have not occurred equally amongst all Ontarians.

"We already knew from previous work that there was greater access to MRI scans for richer Ontarians. This study shows that access has improved but it looks like it has not been shared equally," says principal investigator and ICES Scientist, Dr. John You. "It's well known that, on average, poor people have more health problems than the rich, so the trends go against what we would have expected.", says You, who is also an assistant professor of medicine and clinical epidemiology and biostatistics at McMaster University. "Although many of us pride ourselves on Ontario's universal hospital and physician services, our study highlights the need for simultaneous strategies that aim to improve the appropriateness of MRI scanning, so that access is based on medical need."


That last sentence seems slightly ominous, "strategies that aim to improve the appropriateness of MRI scanning" in other words wait lists and rationing are coming back. They spent all those millions and it only benefited the wealthy. The government bureaucrats never learn this simple law of economics, if something is free or relatively free it will be over-used by the public and the only way to limit it's use is to make it so difficult to obtain that only the most desperate will put up with the wait lists and rationing.

Here is a radical idea: how about letting the free market work? In America -- at least for the time being -- if there is a shortage of MRI machines in the city a savvy entrepreneur can buy some machines, rent a space and open up for business. A few years back I needed a MRI scan, my doctor didn't send me to the hospital located next to his office, he sent me to a privately run facility. The appointment was a few days after my visit to the doctor, there was no waiting. My insurance paid most of the cost and the owners of the facility made some profit.

Now imagine you are a government bureaucrat running a government health care program. There is no incentive to buy more MRI machines, it's only going to cost the government more money. You would do everything you could to get by with what you have.

While it is true that there are inequities in our current health care system, this study shows that adopting a system like the one they have in Canada will not solve the problem.
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