Canada, eh? Don't fall for these tired old canards about health care rationing

The specter of health care rationing is rising again! Most recently, New York Times columnist David Brooks weighed in on the perennial topic of Canadian health care rationing. Brooks argues that single-payer health care as practiced by the Brits and Canadians would never fly here, for all the reasons we’ve heard for decades.

He constructs most of his argument around the notion that if we pay less for health care, it would pinch the pocketbooks of providers up and down the health care food chain. “The government could set prices and force health care providers to accept current Medicare payment rates,” Brooks argued, and noted Medicare reimburses hospitals at 87 percent of costs while private insurance reimburses at 145 percent.

He cites the work of Charles Blahous, a former Medicare public trustee who once worked in the George W. Bush administration on Social Security privatization. Blahous, who now works for the libertarian Mercatus Center, estimates that under the “Medicare for All” plan proposed by Sen. Bernie Sanders, the government could pay providers about 40 percent less than what private insurers now pay.

The implication is that the drop would be a bad thing because it would bring unwanted and unaccustomed change to all health sectors. The subtext is that if providers get less money, they may not provide care, another of those perennial memes floating around.

Never mind that U.S. health care spending is quickly climbing toward 20 percent of GDP, and the need to bring that spending more in line with other nations by controlling costs is precisely what the opposition to Medicare for All and its many iterations is about. According to the latest report from The Commonwealth Fund, the U.S. ranked dead last in a comparison with 10 other countries on various measures. It also ranked at the bottom when it came to equity, access, and health care outcomes. On the access measure, 60 percent of doctors report patients have trouble paying for medicine or out-of-pocket costs, twice as much as the next highest countries.

No health care system can afford to give citizens all the care they desire when they want it. There is always some lid on what they can provide, and who gets what when.

Brooks ends his piece with that old canard about rationing in Canada, citing a nine-month wait time to see an orthopedic surgeon. Americans wouldn’t stand for such delays, he says. It “would take some adjusting.” He leaves the impression care is not rationed in the U.S. People here get care, pronto. The Commonwealth study suggests otherwise.

No health care system can afford to give citizens all the care they desire when they want it. There is always some lid on what they can provide, and who gets what when.

In Canada there’s always a balance between creating equitable access and controlling costs, says Jennifer Verma, a senior director of the Canadian Foundation for Health Care Improvement, a group that works across the country to improve outcomes. That’s true in England, too, where patients may have to wait for some kinds of back operations, as a friend of mine did, but the country has chosen to give free prescriptions to citizens over age 60 for most kinds of medicines. In America, by contrast, seniors often have to choose between buying food or paying for prescription drugs.

That the U.S. rations care by patients’ economic status and price is a truism we haven’t acknowledged until recently. The poorer you are, the less likely you’ll get the care. No longer, though, is evidence of this inconvenient truth hidden from public view.

The latest example is the current uprising over pharmaceutical prices. Sam Baker, health care editor at Axios, used the “R” word in a piece headlined, “How Americans ration their health care.” He cited stats from the CDC showing that 11 percent of adults don't take their medicines in the way they should to keep their drug costs down. What was remarkable was that Baker used the "R" word that usually doesn't appear in news accounts of the country's health system.

David Mitchell, a former PR executive who now heads Patients for Affordable Drugs, a grassroots group that has been gathering attention, cited the rationing stat as evidence of “a broken system.” I recently talked with two women who have been working with Mitchell’s group. Sabrina Burbeck of Old Town, Maine, is a home health aide and can’t work more than 29 hours a week to keep her 6-year-old son, a Type 1 diabetic, on a special health plan offered by the state. She lives in Section 8 low-income housing and can’t afford the $800 to $900 a month for insulin and other supplies. What will happen when he ages off the state program? she wonders. Will he have to choose between insulin and going to college?

That the U.S. rations care by patients’ economic status and price is a truism we haven’t acknowledged until recently. The poorer you are, the less likely you’ll get the care. 

In 2017, Nicole Smith-Holt’s 26-year-old son Alec did die because he rationed his insulin. Alec had been a Type 1 diabetic for two years and had recently left his parent’s home for his own apartment and a job in management at a small restaurant that did not offer health coverage. He had aged off his parent’s health insurance, Smith-Holt said, and he believed an Obamacare policy with sky-high deductibles ranging from $7,000 to $10,000 was unaffordable. He was too proud to ask his parents for help.

When a pharmacist told him he’d have to pay $1,300 for monthly diabetic supplies, a cost mostly driven by insulin, he decided to ration the amount of the drug he had left. Three days before payday, he died from diabetic ketoacidosis.

Alec’s story, which has been widely told, is more than a tragic miscalculation. It’s  fundamentally a story about American health care policies that for decades have imposed rationing on some its most vulnerable citizens.   

Medicaid, too, is becoming a prominent example, particularly in states that did not expand their Medicaid programs under the Affordable Care Act.

Nannette Ruelle, who was one of 18,000 people kicked off Arkansas’ Medicaid program for failing to comply with new work requirements, began rationing her medications last November. She couldn’t get health insurance again until January because she failed to report her work hours through an online portal she didn’t even know existed. Meanwhile, Ruelle became a victim of the state’s policy to ration health care to its residents.

Last week, the Trump administration ratcheted up rationing even more. It approved the Utah legislature’s plan for very limited Medicaid expansion, which offers health coverage only to those with incomes up to the federal poverty line, not 138 percent as called for by the ACA. And the state can cap the number of people served if spending exceeds budget expectations. Those people just over the line presumably won’t get much care unless they pay for it, which will be difficult given their incomes.

Even though a federal district judge has struck down work requirements in Arkansas and Kentucky last week, such rationing is likely to continue. Seema Verma, who runs the Centers for Medicare and Medicaid Services, said in response to the ruling, “We will continue to defend our efforts to give states greater flexibility to help low income Americans rise out of poverty.”

Since Brooks mentioned the Canadians, I checked in with some Canadian health policy experts who know their system well.

Kathleen O’Grady, a research associate at Simone de Beauvoir Institute at Concordia University and author of books on health policy, wanted me to know about the “top quality care” she got when what might have been a mini-stroke turned out to be a visual migraine. “They ran me through tests with incredible speed. It was efficient and thorough and all my follow-up was within a month,” she said.

That doesn’t mean it’s a perfect system. When it comes to evidence-based therapies for autism, “our system has not found a way to triage needs,” O’Grady said. Mental health and addiction services as well as options for home and community based services are also weak spots in the Canadian system, Jennifer Verma pointed out.

As for the waiting lists, the federal government had established targets for reducing waiting times for knee and hip replacements, says O’Grady. “We had a national strategy and we had great success,” she told me. “But when they tried this for mental health, it was less successful.”

Just released numbers from the Canadian Institute for Health Information (CIHI), an independent organization that provides information on Canada’s health system, show that while almost all Canadians are receiving radiation therapy in the recommended time (a problem at one time), and 88 percent are getting hip fracture repairs in a timely way, waiting lists for less urgent services like some hip and knee replacements and cataract surgery are going up. The waits vary from province to province.

When the provinces have targeted strategies, they’ve been successful, O’Grady said. When they haven’t had them, they’ve been less successful. But she added, “People in Canada aren’t going bankrupt to get basic care.”

In the U.S. the struggle to provide health care for everyone goes on.

“The frustrating thing is that we don’t have a lot of discussion about this stuff,” says Clayton McCook, an Oklahoma veterinarian who is working with Mitchell’s group. He, too, has a child with Type 1 diabetes and a wife who has needed drugs to treat breast cancer. Even with good insurance, the family still spends about $20,000 each year out of pocket. “We throw up our hands and put labels on solutions like socialism and rationing. It doesn’t help people pay for their medicines.”                                                                 

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.