Worthwhile Canadian initative: health care edition

I’ve been blogging a lot recently about the various ins and outs of the  Affordable Care Act and it is implementation. (See here, here, and here for example) However, let’s keep our eyes on the ultimate prize:

That’s an Ontario Health Insurance Plan ID card -- the provincial manifestation of Canada's universal Medicare system. One of my Canadian friends showed me hers about six years ago when we were working on a health-care proposal to show university administrators during labor negotiations.  That simple card, she explained to me, guaranteed her access to any clinic or hospital in Ontario. We looked at the magical talisman sitting on the table for a moment, sighed and got back to work.  

With that tantalizing thought in mind, let’s compare current user experiences between an American and a Canadian.  Just to make things interesting, we’ll assume the American has decent health insurance. Follow me below the fold for a comparative experience in health care.

Scenario #1: routine visit for medical condition

The American schedules an appointment with their doctor’s office, shows their insurance card, sees the doctor. She then visits the desk, pays the applicable co-pay (usually anywhere from $15 to $30) and leaves.

The Canadian schedules and appointment with their clinic or doctor’s office.  She shows her OHIP card, see the doctor and leaves. 

Scenario #2: A semi-urgent medical issue comes up while our protagonist is away on business in state/province 

The Canadian schedules an appointment with the nearest clinic or doctor’s office. She shows her OHIP card, sees the doctor and leave.

The American has to find the nearest doctor’s office in network, which might not be the nearest one. If there is not a nearby doctor’s office in-network, she has to get pre-approval from her insurance company for an out-of-network visit. The co-pays will generally be higher if the visit is approved and the patient might be on the hook for additional costs even if the visit is approved.

Scenario #3: A semi-urgent medical issue comes up while our protagonist is away on business out of her home state/province 

The Canadian schedules and appointment with the nearest clinic or doctor’s office. She shows her OHIP card, sees the doctor and leaves. Manitoba’s health bureaucrats bill Ontario’s health bureaucrats according to an existing interprovincial agreement.

The American has to find the nearest doctor’s office in network, which might not be the nearest one. If there is not a nearby doctor’s office in-network, she has to get preapproval from her insurance company for an out-of-network visit. The co-pays will generally be higher if the visit is approved and the patient might be on the hook for additional costs even if the visit is approved. Note that it is much less likely that an out-of-state provider will not be in-network, increasing the degree of difficulty for our hypothetical American. She sees the doctor and leaves.  Costs and paperwork will follow if things go well. A multi-month fight with the insurance company ensues if things do not.  

Scenario #4: Emergency Care in another province/state far from home during a vacation thanks to a freak snowboarding accident

The Canadian gets transported to the nearest emergency room. She shows her card. She gets care, she gets better. She goes home. British Columbia’s health bureaucrats bill Ontario’s health bureaucrats according to an existing inter-provincial agreement.

The American gets transported to the nearest emergency room. It likely will not be in network. She shows her ID and does not have to get pre-approved, but needs to call her insurance company as soon as possible. The co-pays will be higher than if she had gotten emergency care near home. She gets care. She gets better. She goes home.  Significant costs and paperwork will follow if things go well. A multimonth fight with the insurance company ensues if things do not.  

By the way, the Canadian’s medical records will easily transfer. The American’s may or may not.

In all four scenarios, both our protagonists receive care. But the American pays significantly more and goes through more bureaucratic hassles. The Affordable Care Act will greatly increase access to insurance and care for Americans. It will also considerably streamline bureaucracy, and limit some out-of-pocket expenses as well. But it won’t solve the out-of-network problem.

Finally, note that the final improvement doesn’t have to be single-payer system or free at the point of service (though single-payer is a fine outcome). We could also end up with more of a Bismarckian system like Germany or France – where you always owe a small (transparent, sliding scale based on wealth) co-pay for services.

But the overall point remains. The ACA is a major step forward for the U.S. healthcare system, but we will still have a ways to go to improve the consumer experience even when it is phased in completely.