David R. Henderson  

Did Natasha Richardson Die from Socialized Medicine?

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Clyburn Undercuts Own Case... You Will Know the Disgrace...
The province of Quebec lacks a medical helicopter system, common in the United States and other parts of Canada, to airlift stricken patients to major trauma centers. Montreal's top head trauma doctor said Friday that may have played a role in Richardson's death.
"It's impossible for me to comment specifically about her case, but what I could say is ... driving to Mont Tremblant from the city (Montreal) is a 2 1/2-hour trip, and the closest trauma center is in the city. Our system isn't set up for traumas and doesn't match what's available in other Canadian cities, let alone in the States," said Tarek Razek, director of trauma services for the McGill University Health Centre, which represents six of Montreal's hospitals.

This is from "Doctor: Lack of Helicopter Cost Actress."

The essence of "single payer" medicine is that no one other than the government is allowed to pay for medical care. Thus the term "single payer." There are a few exceptions in Canada but, by and large, the more serious the ailment, the more stringent the ban. So, for example, if you want to be treated for cancer in Canada, you can not do so legally and any doctor or hospital that tries to charge you faces serious penalties, up to and including a prison sentence. In that sense, Canadian health care is one of the most totalitarian systems in the industrialized world and is far more extreme than the National Health Service of Britain.

Bill Anderson points out:

However, because no one can charge medical consumers for anything in Canada, the decision to purchase an MRI machine is purely one of cost. Medical facilities have only so much money to use, and the purchase of a device that performs MRIs means funds are drawn away from paying medical workers.

In Britain, people who don't like the long lines and sometimes low quality of the NHS can pay for better themselves and can even buy insurance for this higher-quality care. This is Britain's safety valve for socialized medicine. And Canada's safety valve? It's called the United States. In David R. Henderson and Charles L. Hooper, Making Great Decisions in Business and Life, I tell my own "safety-valve" story involving my father, who spent his whole life in Canada.


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COMMENTS (32 to date)
Teresa Lo writes:

Tremblant is a rural resort town not unlike many of the exclusive skiing venues around the world. While it is very sad that Ms. Richardson died after what amounts to a freak accident on the slopes, we must also ask how many people in the U.S. die from not having any healthcare.

Oliver writes:

One of the ways to recognize ideological rhetoric in the discussion on health care, is to check whether the author simplifies the discussion on health care by only quoting from the Canadian or British health system, not bothering (usually on purpose) to compare these systems with the better performing hybrid Western-European system of non-profit insurance companies + for-profit health practitioners. David Henderson: check.

For those inclined to research these matters a bit more in depth, and who wish to be saved from anecdotal evidence such as above, google 'EHCI Report 2008' (can be downloaded in full via www.healthpowerhouse.com).

Slugger writes:

The Richardson tragedy is an extremely unusual event, and pending an autopsy, none of us know if this event was preventable.
One of my friends did break his leg skiing at Chamonix. He was heli-evaced, had reparative surgery within two hours of the injury, and spent a week in the hospital recuperating. Because he is a US citizen, they made him pay a copay for all of this service. It was $700 US for the whole thing. BTW, he says that the hospital food was delicious, and wine was served!
Anecdotes make a poor basis for analysis. Michael Kennedy or Sonny Bono were not saved by the US system.
Please note that I am not arguing for any particular medical payment system. Let's look at these issues with a bit deeper look.

Charlie writes:

In Canada, doctor's CAN charge people directly for medical services, instead of billing the province's single payer medical insurance. In fact, when the patient is not a resident of Canada, the doctor must charge that person directly, because that person would not be covered by the government insurance system.

What doctors in Canada cannot do, is charge that person anything higher than what the government insurance system would pay for the service provided.

So, for example, if the insurance system pays $50 for an office visit, the doctor cannot charge someone who is not in the insurance system any more than $50 for an office visit.

The reason for this is simple. If doctors were able to charge more, it would create a two tiered system where the people who had money would be able to get treatment before those who don't. This way, treatment is based on severity, not on how much money you have.

RickC writes:

Teresa Lo,

The research claims that in the U.S. around 20,000 die annually as a result of having little access to healthcare. Research has also shown that around 100,000 die from preventable medical mistakes. So name your poison.

Oliver,

So the folks who drew up the EHCI 2008 report had no ideological or politic agenda in mind? Right.

Charlie,

Wasn't Canada trying to outlaw the ability of doctors to directly charge people for their services?

RL writes:

Ms. Richardson died of the effect of an epidural hematoma. (I made this dx provisionally on the initial reports alone and it was subsequently confirmed in other reports.) That is to say, she had trauma that led to a tear in an artery between the skull and the brain, initially not terribly painful and causing no severe immediate symptoms, but over the next hour or so, a growing blood collection compressed the brain and I suspect ultimately caused brain herniation and death.

In such a situation, the time between onset of significant symptoms and irreversible neurological decompensation/death is very short. If it happens on a hillside in a remote and rural part of a country, it's hard to imagine a sensible distribution of scarce resources that would save every life in such a situation.

So while I share Dr. Henderson's concern about the downside effect on quality patient care in universal health care environments, I'm not convinced this is the best case to demonstrate such problems.

PS: Slugger, as far as bad arguments go, Kennedy and Bono were both dead at the scene. I'm not sure it matters what kind of health care system was in place in such cases. Richardson's death, though also on a ski slope, was very different.

RickC writes:

Oh, the Richardson case has no bearing on the ongoing discussion surrounding healthcare. She refused treatment from the EMTs and went to her room. The autopsy revealed that she had torn an artery inside her skull. By not allowing doctors to examine her she made an unlucky choice that quite probably cost her her life. The big lesson here is that any head injury should be investigated by medical personnel.

David R. Henderson writes:

Dear RL and Oliver,
Because I know RL personally and know that he is an excellent doctor who gave valuable information to my sister-in-law, I will defer to his judgment about the case. Notice that I asked whether, rather than asserted that, Natasha Richardson died from socialized medicine. The answer is clear: she didn't.
To Oliver, I don't get your point. It made sense for me to talk about Canada and the U.K. because that's what I was talking about. I was comparing those two countries. And, contrary to your claim, I actually think well of the British hybrid compared to the Canadian extreme. That's why I wrote:
"In Britain, people who don't like the long lines and sometimes low quality of the NHS can pay for better themselves and can even buy insurance for this higher-quality care. This is Britain's safety valve for socialized medicine."

LJ Gould writes:

Healthcare in Canada does not work the way you've described it. For the most part, the government merely replaces the role of insurer: medical services are delivered by private businessmen (doctors, and clinicians).

In Quebec, Air Ambulance services are provided privately or publicly, at a cost of $630.00 per flight. Ground ambulances cost $125 + extra fees for distance. Quebec also has private MRI clinics, some of which have surcharges above the amount covered by the provincial health insurance. As long as it's profitable, the services will be available.

Doctors are more constrained by the fee guide established by the province, than most US doctors are by insurers' guides, though there are work-arounds like Block Fees. The provinces do drive down availability of services by making the fees too low.

Hospitals in Quebec, though (Shawville excepted) are mostly public enterprises with salaried employees, which therefore face the incentive problems noted above.

There are two big factors in availability of medical services: one is population density - Canada has 1/10th the population of the U.S. spread over a larger area. Outside of major population centres access to certain medical services is much less likely, and costs are higher whether provided publicly or privately.

But the big culprit is the power of the medical association (i.e., the Doctors' union) which has made regulatory capture an art form. They constrained the supply of doctors by reducing the spaces and increasing the requirements of med. school, leading to a shortage, so that there really is little need for doctors or hospitals to compete for services. Nurses setting up practice or prescribing meds, etc, while legal in some limit jurisdictions is simply not allowed in others, further limiting supply of diagnosticians etc. Most of this was done in the name of 'safety'.

This varies province to province, but it's more a classic case of a everyone losing when big unions and big government get together, than an indictment of universal health insurance itself.

The real problem of universal insurance is that the insurance costs are geared to income, rather than to personal risk, and there are no extra charges for dangerous behaviour (e.g., freeform rock climbing); basically government subsidized bad behaviour.

RL writes:

LJ Gould,

Correct me if I am misinformed, but I understood the Canadian system places caps on medical payment. For example, if you're a radiologist (and I used to work with a radiologist formerly from Canada) and the system allocates $X/yr for radiology services, and you've reached that cap by September, you don't get paid for any radiologist services in Oct/Nov/Dec. That would seem to create an incentive to not offer as many radiology services earlier in the year as people seem to want (or for all radiologists to take 3 month vacations at year's end). It's a form of rationing. That usually is the problem with single-payer systems.

You seem to admit this when you write, "Doctors are more constrained by the fee guide established by the province, than most US doctors are by insurers' guides" Am I wrong to suggest this is something more than, as you put it, "the government merely replaces the role of insurer"?

And I agree that Dr. Henderson was merely raising a question rather than making an assertion and hope my earlier post did not suggest otherwise.

Oliver writes:

Dear David, RickC. In reply to the last comment of David: You stated that you think well of the hybrid UK system, but that seems to imply that you think the UK system is better than the Canadian because they have a private safety valve? The EHCI report puts the U.K. behind the majority of western european countries because it combines the worst of both worlds: state-run hospitals with average service for the masses, and top notch service for the well off. We disagree in that I think continental Europe is more of a safety valve to U.K. citizens than the unaffordable private hospitals.

RickC. Given that the EHCI report only compares european countries --showing for example how the systems in Austria, Netherlands, France or Germany are the best in Europe when looking at a wide range of indicators-- and doesn't include the U.S. or Canada, I don't see how this is ideological, as you wrote. Except if the researchers wanted to bash the more socialized systems in Europe (U.K.), and illustrate how the hybrids are performing much better.

U.S. health care is of outstanding quality, but it comes with a steep price and hampered accessability. Looking at these alternative systems will broaden the discussion beyond constant comparison between the U.S. on the one hand and Canada/UK (or sometimes ridiculously Cuba... I'm looking at you, Michael Moore) on the other hand. In the meantime, I would not hide behind question marks put after a one liner of how socialized health care might have killed this or that person. I know it's just a blog post, and I'm just writing a minor comment, but I found the title inflammatory, indeed in a Michael Moore kind of way.

Anthony writes:

People dying from not having healthcare in the US? That's a flat out lie. People in the US don't die from not having healthcare, that's a farce, made up by the left years ago. It's ILLEGAL for a hospital to turn ANYONE away for not being covered with healthcare. Sure, they may not get as good a care as someone with better insurance but there are a few things that push up the cost of health care in this country. 1. Illegals, ESPECIALLY in the west and south west. California, bankrupt- that's a big reason why- illegals! Get rid of em'! 2. Health insurance scams. 3. The cost that goes into R&D for medicines. We produce more life saving medicine than any country out there and have about 50 big pharmaceutical companies, the next country with the most being Germany with only around 4 pharmaceutical companies. That's what a healthy capitalist, competitive system does, create better LIFE saving products! So while people bitch about the costs, even if someone were to show up at a hospital with NO insurance, our medical system, our hospitals in general still give better care than a hospital in a country with socialized medicine AND on top of it, the medicine that is administered to you was most likely created in the good ol' US of A. Sure, the system isn't perfect. Want to tweak it a bit, sure, it needs some tweaking but socialize it? Don't be stupid. You'd be writing your own script for death!

Charlie writes:

RichC,

As stated, in Canada doctors can charge patients directly for the services they provide to them, and in fact that is what doctors do when the patient is not covered under the government insurance system (ie. when they are not a resident of Canada).

What doctors are restricted from doing is charging patients a fee that is higher than what the government insurance system will pay for that service (regardless of whether or not the patient is covered under the insurance system).

Each year, in each province, the medical associations and the government insurance programs meet and set a list of prices for the services that are covered under the insurance program.

Since a doctor cannot charge a higher fee than what is specified by the insurance program, there is no benefit for that doctor to directly bill a patient who is covered under the government insurance program. Only when the patient is not covered under the government insurance program would the doctor directly bill the patient.

All this being said, doctors are given the option of billing their patients a higher price than what the insurance program will pay BUT if they choose to do this then they are not allowed to bill the government insurance program at all for any patient. They must totally opt out of covering any patients under the government program. Virtually no doctors will choose to do this, because it would severely limit the number of patients that they'd be able to treat.

Charlie writes:

RJ,

Regarding caps on medical payments under the "Canadian System", it is important to realize that, in actuality, there isn't just one "Canadian System". Each province is responsible to run its own health insurance plan for the residents of that province, and each plan has its own rules. The federal government in Canada helps each province to fund their plans, and to see that each province offers at least a minimum level of service, as specified by the Canada Health Act.

I can't talk about Quebec, but in Ontario - Canada's most populated province, there used to be a cap on how much doctors were allowed to bill the insurance system in a year, but the cap lifted in 2006. Prior to the cap being lifted, the cap in 2006 would have been $475,702. At that time, the average general practitioner billed the Ontario Health Insurance Plan an average of $213,000, and ophthalmologists had the highest average billing to that province's insurance plan of $454,000.

I can't answer for the plans in other provinces, but there is no longer a cap in Ontario.

Dr John Crippen writes:

These comments about "socialized" medicine do not sit well when juxtaposed with the 40 million plus American citizens who have no medical insurance at all.

For all the faults of the NHS in the UK (and there are many) there is not a single UK citizen who cannot access health care due to lack of money or lack of status.

I cover Natasha Richardson's tragic death here in Natasha Richardson tragedy

Whatever you may feel about it, this is not a reason to start yet another diatribe against so called "'socialized" health care. You should worry more about what one of your eminent medical commentators has called:

The "wussification of the American Medical Profession"


Dr John Crippen

NHS BLOG DOCTOR (UK)

lukas writes:

Dr Crippen,

People who lack medical insurance can still have access to health care. They'll only have to pay for it directly. In the US, they don't even have to pay in emergency cases thanks to EMTALA.

The Shrink writes:

As a doctor working in the UK I strongly take issue with your comment, ". . . can pay for better themselves and can even buy insurance for this higher-quality care."

It simply is not true. Private healthcare is not better than NHS health care. A doctor giving one standard of care in the NHS and a "better" standard in private practice would be practising unprofessionally and unethically.

Indeed, private healthcare can routinely be much worse than care within NHS services.

Babinich writes:

"These comments about "socialized" medicine do not sit well when juxtaposed with the 40 million plus American citizens who have no medical insurance at all."

Some perspective is necessary here:

http://www.nypost.com/seven/03022009/postopinion/opedcolumnists/bams_bad_medicine_157651.htm

Rob Matthews writes:

A helicopter is not medicine; it is a helicopter.

LJ Gould writes:

RL,

It's complicated. Canada doesn't really have one healthcare system, it has 14 separate ones (provinces/territories and military) that use different fee/billing practices. Caps are part of some of them. Quebec sets quarterly expenditure caps to try to:

Enforce restrictions on the number of hours medical professionals can work in a set period of time by not paying them for more services than they can legal perform;

Reduce supplier-induced demand (e.g., excessive follow-up visits) that can be a problem in jurisdictions without user fees; and,

Cap overall costs.

For the most part these restrictions apply to specific medical professionals rather than whole areas. The private MRI clinics, etc. aren't limited in the amount of services they can bill - if it's a medically necessary referral from a GP the province will pay, otherwise the user or their supplementary insurance will pay, regardless of the total billed.

That said, jurisdictions have also tried "Global" expenditure caps on certain services, that work exactly like you mentioned, but the way the structure works has considerably changed in the last decade. Some of the other jurisdictions don't have similar caps at all, and those that do have different rules about how they work, and what does and does not fall under the cap, and different levels of enforcement.

In general, the restrictions have eased since the 90s when many provinces were facing huge deficits. And even where the caps are still in place, they're set higher now.

Frankly, I think both kinds of caps are bad policy. It's those caps and the restrictions on the number of phsyicians, rather than the set fee-for-service and single-insurer model that causes the supply constraints. I generally favour small user fees as a way of reducing demand for services as a way of constraining costs instead of a control like this that limits supply.

Politically, though, user fees in Canada are suicide.

Amanda0970 writes:

I'm slightly disturbed by this post. I had NO IDEA Canada's system was this bad. The idea of socialized medicine came up in my global issues class last year, and although the lack of emergency care is not the best way of caring for a country's citizens, this is the way it was presented to me:

1.) overall health statistics were improved, since the focus of most socialized health care systems is preventative care. Chronic conditions and the huge costs associated with them are drastically reduced.

2.) all citizens receive the same level of care.

The downsides include:

1.) lack of incentive for physician & technician performance, and investment in certain technology

2.) long lines and inadequate facilities, plus frustration from unmotivated employees such as receptionists and transcriptionists, etc. which in turn frustrates citizens and lowers morale behind the government.

Long story short.

But as Mr. Henderson mentioned, Britain has a "safety valve" for patients whose conditions could not be prevented with socialized medicine: the option for purchasing better health care. This is the key to finding the happy medium between the United States' wacked-out system that excludes the poor and over-benefits the rich, and the neglectful system of Canada. Canada has no safety valve other than us, the people who have no alternative other than the safety valve.

So I think, yes, Natasha Richardson was just a more famous and paid-attention-to casualty of Canada's socialized medicine.

Kurbla writes:

Canadians have 2 years higher life expectation and 20% lower infant mortality at 20% lower GDP/cap. than USA.

Mr. Econotarian writes:

Telluride, Colorado, is a high-end ski area which is pretty much in the middle of nowhere. Nonetheless...

"The Telluride Medical Center is a full-service, 24-hour medical facility with emergency ambulance and helicopter service to neighboring hospitals. A certified Level V Trauma Center, the medical center is the first stand-alone clinic not associated with a hospital to receive this designation in the state of Colorado."

http://www.heartoftelluride.com/faq.html

lukas writes:

The higher infant mortality in the US is due to more live births... Some of the infants that die in the US would likely have died in Canada, only without being born first. This is what keeps Canada's stats lower.

Life expectation depends on a lot of factors. Nutrition and exercise are at least as important as a good health care system. And those artificial infant deaths push it down too.

Not to say that the US system is perfect but it could be a lot worse.

BlackSheep writes:

The Shrink writes "Indeed, private healthcare can routinely be much worse than care within NHS services."

Why do people patronize such institutions then?

Francis writes:

Amanda,

I'm a citizen of the Province of Quebec and I can say that what they told you in your "global issues" class were dreams, not reality.

1. "The focus is on preventive care": totally false. No preventive care, at all. You are ill, you see the doctor, he tries a fix. Period.

2. "All citizens receive the same level of care": the reality is that some citizens are more equal than others. It's an open secret that 95% receive the same level of mediocre care. The other 5% of the population consisting of celebrities (show-business, sports, etc.), politicians, insiders of the system, and yes, rich people, get VIP treatment. (See for example Question 3 of
http://www.coa-aco.org/fr/library/practice_management/
private_orthopaedic_surgery_is_legal_in_canada.html).

Francis writes:

I don't know much about the statistics, but as a citizen of the province of Quebec, father of two, I can tell a lot about the usual experience of health-care users here.

So, suppose you are an average citizen in Quebec (not a celebrity) and the same accident happens to you as happened to poor Natasha Richardson.

1. You bumped your head, and you don't feel really well.
a) But you know the "walk-in" clinic is in fact filled up since its opening hour (the waiting line started outside the clinic an hour before the opening time).
b) You also know that the "emergency" room of the hospital is also full and you will have to wait for hours.
c) So, you choose to keep doing your day as usual, saying to yourself it's probably just a bump.

2. Now it really starts to worry you, as it gets worse.
a) You try the walk-in, just in case. You enter and barely notice the not-uncommon sign "The direction will not tolerate verbal or physical abuse by patients toward the personel".
b) It's full, as expected. So you go to the "emergency" room of the nearest hospital.
c) You enter, barely notice the sign again, and tell a bored clerk why you come. He evaluates the problem and assigns you a place in the queue. (You can't know your place in the queue, of course, neither the expected waiting time.)

2. Now you wait. You have perhaps an 8-hour waiting time in front of you (not unusual), like my colleague whose pregnant wife, last week, waited that time bleeding, during a miscarriage.

3. As you get worse, you think you may ask the clerk to be seen earlier.
a) Most of the time, the clerk will politely say "no", that he has many emergencies, and that you unfortunately have to wait.
b) Sometimes, though, you can be told, rudely: "no".
c) Or, like my colleague witnessed while he was waiting, the clerk can take an arrogant tone and shout in the waiting room: "There is someone here who wants to see the doctor sooner. Is there anybody who wants to leave him his place in the queue? No? I'm so sorry."

4. Now you throw up. They react. (As was the case for another colleague's wife when she finally delivered in the bathroom of the waiting room. My colleague had to be thrown out of the hospital by Security. He hadn't seen the sign, I suppose.)
a) They will get you to the doctor at once on a bed, although the bed will likely be placed in the corridor.
b) The doctor will see you now, but he/she is as likely as anywhere else to provide a wrong diagnostic (like happened to my sister in law, who was not diagnosed for cancer soon enough and is now struggling hard against it.)
c) Or the diagnostic is the right one but it is too late. I know no stastistics about how many people die or suffer in Quebec for waiting too long in the line-up, but THAT should be compared to statistics of people dying or suffering because healthcare is too expensive in the U.S.
d) Or the diagnostic is the right one, it is not too late, and you are now taken care of. In the corridor, though, until a room is available for you.

All what is written above is neither made up, nor exaggerated. It is common experience in Quebec. Poor Natasha Richardson has not died of socialized medicine. Nor would have she, because she is a celebrity. But too many families in Quebec have horror stories about parents not being treated in time, and all of them have horror stories about suffering uselessly in waiting rooms.

Marie writes:

Bull.

For every horror story, there are numerous examples of people being treated timely, and being fully satisfied with the health system, in Quebec, in the rest of Canada, and in other countries around the world.

Francesca writes:

[Comment removed pending confirmation of email address and for rudeness. Email the webmaster@econlib.org to request restoring your comment privileges. Read about EconLog policies here. --Econlib Ed.]

Manuela writes:

Well, I am appaled at what you are saying about the health care system in Québec!

People that talk in such a way about the system either don't know what they are talking about or haven't been in life-and-death situations.

I am a quebecer and my life and my family's life have been saved several times by the system.

Sure the emergency rooms are crowded. Sure it takes time to get to see a specialist. But when it is a matter of life and death, it is the best system in the world. We have competent doctors and nurses that are always fighting for their patients, regardless of the money they have or their celebrity status.

I am sick and tired of people that want to privatize the system. In fact, the only part of the system that I DO NOT TRUST is the private one. I don't trust the private blood clinics or the private radiologist as much as I trust good ol' university hospitals.

Those that complain about the system and want a change are the ones that don't know what it means not to have health insurance and having a life threatening disease or in the event of the sickness of a loved one have to think about where the money to pay the bills would come.


In Québec, we just have to worry about ourselves and our loved ones, not about money.

It is not a fancy system, but it is the best system.

LL writes:

The 911 tapes now exonerate Canada from any wrong doing. Natasha Richardson reached the first hospital after an 8 minute ride, and the trauma center after 40 minutes. A helicopter would not have been faster in this case because loading time takes longer.

An injured skier in Colorado would not have better transfer time. In fact, 2 skiers recently died of the same injuries as Natasha Richardson in this past month alone.

coffee fan writes:

Natasha's passing is a shock indeed; it's a reminder that we should live everyday like it's our last

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