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October 17, 2005

Another Myth Bites the Dust

Kate has a terrific post up summarizing some research done into Canadians crossing the border for care. Put shortly, it doesn't happen:

The authors used some nifty methodology, including surveying numerous US hospitals along the border, as well as institutions generally regarded as "America's Best Hospitals". On the Canadian side, they used the National Population Health Survey (which literally asks, "In the past twelve months did you receive any health care services in the United States?" and "Did you go there primarily to get these services?"), as well as querying insurance companies on the Canadian side about the popularity of policies that cover US institutions.
[...]
the most striking stats come from the Canadian National Population Health Survey (NPHS). From the article:
"Only 90 of 18,000 respondents to the 1996 Canadian NPHS indicated that they had received care in the United States during the previous twelve months, and only twenty had indicated that they had gone to the United States expressly for the purpose of getting that care."
Only 20 of 18,000 sought care in the United States. I can't believe how many people are coming over here! Their system but be truly awful.
[...]
Polling data from 2003 (approximately a year after the Health Affairs article) indicates that 8% answered YES to the following question:

"Have you ever bought prescription drugs from Canada or other countries outside the United States in order to pay a lower price?"

If 8% of the 18,000 Canadians polled in NPHS had expressly sought care in the United States, that would be 1,440. Not 20, as the survey showed.

Read the whole thing. The scare tales of Canadians flooding across the border for access to our health care system are simply untrue. Indeed, the number of Canadians coming here is dwarfed by the number of Americans escaping over there for cheaper drug prices. As it is, the research proving that has been floating around for years, it's just that the Republicans in the debate hide from it and the Democrats don't know about it. That has to stop. So head over to Kate's place and spread the word -- in the health care debate, the facts are on our side, but that means nothing if we don't know them.

October 17, 2005 in Health Care | Permalink

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Given the number of Canadians who visit the US for vacation, business or study, one would expect a much higher number of people seeking medical care in the US just because they happen to be here when thet get sick. Could it be that some/many of those who fall ill here wait until they get back there for medical care?

Posted by: john casey | Oct 17, 2005 2:53:59 PM

Remember, the number here is out of a random 18,000 polled, so you'd have to extrapolate out to the population. It's really the percentage -- one tenth of one percent vs. eight percent for Americans -- that tells the tale. Also, the total number getting American care out of 18,000 is 90, it's just that 70 of those are incidentally sick travellers, only 20 travel here for operations.

Posted by: Ezra | Oct 17, 2005 3:14:43 PM

Long ago, in a far away place (up to the 1960's in the USA ?), unfortunate facts were disputed or minimized, or countered with different facts.

In the brave new world of activist radical conservatives, facts are hidden, countered with non-facts, or simply destroyed by policy makers in government or interest groups before they are known.

One of the first things the Dems should say to the American people about what we believe is that Dems believe in facts and even controversy about facts: the essence of democratic dialogue in a free society.

If we don't have facts available, gather them. When we have facts, make sure they are the best facts. When we have the best facts, discuss what they mean for policy making. When we have policy choices, argue about which choices make the best solutions for a free people. When we are elected, make sure those fact-based policies are put in place as programs - and adjusted as more facts are gathered.

Make sure the people know that the Dem. party believes in facts, and won't base policy on hopes, hidden agendas, religious or philosophical beliefs, big money support, or whatever.

Just the facts, Ma'am.

Posted by: JimPortandOR | Oct 17, 2005 3:50:55 PM

Ezra--You know that aggregator service that the Prospect offers, the Moving Ideas network? Do they just gather what's already being produced or is there any attempt to co-ordinate coverage and the production of policy papers? You don't have to answer that, but I think that it would be great if we could encourage a whole lot of people--and not just bloggers--to write a whole lot of articles and policy papers about the problems with the U.S. healthcare system andd why it's awful etc.

Posted by: Bostoniangirl | Oct 17, 2005 4:26:27 PM

I used work in the survey industry, so this kind of data always interests me. I couldn't find a lot on the methodology of this particular survey but a couple of things come to mind.

First, I took a look at the survey, it is both very long and, by it's nature, very personal. That can do really weird things to responses from selection bias. Doesn't mean that the data is wrong, but with this type of survey you have to be cautious.

Second, the hypothetical 'Canadian user of American Health Care' would be very difficult to accurately sample. They would have to be wealthy enough to afford it comfortably, and wealthier people are, generally speaking, harder to interview. This becomes more true as the length of a survey increases.

I honestly don't know how frequent Canadians come to America for health care. I haven't actually seen many make a huge deal about it, and it doesn't materially effect my concerns about the various nationalized health care problems at all anyway.

Basically, the drug reimportation issue sums up my concerns accurately. The American marketplace pretty much single handedly funds drug research and development. If reimportation is allowed, one of three things will happen. Either the price in America will drop to the same as it is in Canada (with negative consequences on R&D), the price in Canada will rise to that of America (unlikely, the Canadian health care system would have trouble bearing that cost) or, the Drug companies and Canada would be unable to come to a deal and Canada will produce its own drugs violating U.S. patents.

Posted by: Dave Justus | Oct 17, 2005 5:33:22 PM

The American marketplace pretty much single handedly funds drug research and development.

How do you know that the American marketplace isn't single-handedly funding drug advertising and marketing? I keep hearing this canard asserted, but never with any evidence, except a sort of blithe, "well, it's more expensive in the USA, so that must be the reason!" More data, less "proof by vigorous assertion," please.

Posted by: Constantine | Oct 17, 2005 6:08:59 PM

The American marketplace doesn't fund worldwide development. There are any number of drugs that are developed and marketed in Europe long before they become available in the U.S. There are no drugs developed exclusively for the Canadian market not because of the pricing constraints, but because the Canadian market just isn't large enough to justify the expense of development.

Posted by: J Bean | Oct 17, 2005 7:15:25 PM

Dave, I don't think you did look into the methodology. It has nothing to do with personal interviews. E-mail me, and I can send you the study -- but poorly done it is very much not. As for drug reimportation, that's nuts. The 10 Fortune 500 companies of the pharmaceutical industry, in 2002, had profits equal to the other 490 companies combined. It is an absurdly profitable enterprise, and R&D is almost none of that. Indeed, advertising and administration cost two and a half times as much as R&D. Read your Goozner or your Marcia Angell -- this stuff is straight mythology, just like the canadians rushing across the border for care. Sorry bud, but the facts are simply against you here.

Posted by: Ezra | Oct 17, 2005 9:25:24 PM

I'm not sure the 2 points - yours, Ezra, that there are not multitudes of Canadians flowing across the border; and Dave's, that the wealthy are not adequately represented in the data - are actually at odds with each other. Partly, this all seems like a red herring to me - who's said that what is going on is Candaians fleeing their own system en masse? The argument I've heard, and which the study doesn't exactly answer, is that those with the ability to opt out of the system (i.e., mostly wealthy and able to travel) do so to obtain treatments they would otherwise wait for in Canada's system. That's very nuanced, it seems to me, to tease out of a survey pf NHS users in Canada and hospital surveys in the US. The best example, the 600 foreign patients that one hospital saw for Proton radiatikon treatments seems to suggest that such suspicions are not entirely unfounded. It's also worth considering that the response rate from the "America's top hospitals" survey was low and not entirely conclusive; these are the treatment centers, even the authors seem to acknowledge, where the wealthiest would likely go.

It's worth reiterating - one of the biggest problems in America is not one bad, failed system; but a multiplicity of systems. Some are exceptional, and some are worse than awful - and most of that has to do with money and who has it. Reasonably healthy young white collar working people do not generally have the insurance problems of other cohorts; and the wealthy have access to a hospital care system that may indeed be the finest in the world. If we talk about democratizing the whole system and leveling the playing field for all, we are, of necessity, talking about removing some resources from the very wealthy to service others. And that matters, both in terms of being able to sell a plan and to realistically assess all the benefits and dwonsides to major changes. The fallacy is that most Americans believe thay have access to a system set up mainly for the wealthiest (and then the healthiest). I don't think this survey alone will undo those perceptions.

Posted by: weboy | Oct 17, 2005 10:39:24 PM

The last time I saw a study like this (a long time ago), they also looked into where in the US the Canadians were getting their care. The vast majority were in Florida, Arizona, etc.--places were Canadians might like to spend the winter anyway.

Also, there are probably areas in Canada where the nearest major hospital (say, Level 1 Trauma Center) is in the US. If so, I hope there are agreements by which people sick or injured on the Canadian side are brought to the closer hospital, even though it's in the US. (Then again, for all I know, such areas may not exist.)

Posted by: thejtrain | Oct 17, 2005 11:28:57 PM

In order to make any sense of this data, you need to know how many of the 18,000 sought care in Canada, and what they sought care for. Then you could figure some ratios, e.g. of x% of Canadians who sought care for hip replacement surgery, y% stayed home and z% went to the US; of x% of Canadians who sought care for lung cancer, y% stayed home, etc. The numbers as presented by Ezra are worse than useless- they make you think you know something when in fact you know less than when you started.

Posted by: JLR | Oct 18, 2005 1:22:16 AM

who's said that what is going on is Candaians fleeing their own system en masse? ... I honestly don't know how frequent Canadians come to America for health care. I haven't actually seen many make a huge deal about it,

Hmm... this kind of sounds familiar... wait a sec. Oh, right here's where I remember it from:

He would even deny saying something he just said 30 seconds ago. He was famous for that. Students jumped on him; I challenged him." When asked to explain a particular comment, said Tsurumi, Bush would respond, "Oh, I never said that."

It has been a near-constant drum beat from right-wingers about how Canadians flood the United States for health care again and again. It is, obviously, false, when held up to scrutiny, and it's a reason why right-wigners simply aren't credible. Simply trying to desperately find a new set of talking points and trying to deny that one ever argued a bunch of falsehoods in the first place is just a distraction.

Posted by: Constantine | Oct 18, 2005 9:21:46 AM

Constantine is right -- this has been one of, if not the, most prominent claim against Canada's system: it's so bad they come here. The media even refers to them as "medical refugees" sometimes. And, contra some of the comments here, this study strikes me as neither inconclusive nor particularly tough to believe. America's best hospitals, for instance, had a response rate of 55%, not the full spectrum, but more than enough to get an idea. And in the end, that's the point. In American health care politics, the assumption is thaqt Canada has bad health care and its people rush over to use our facilities. With this study, and others like it, the onus should be on the Republicans to prove that claim. As of yet, they haven't.

Posted by: Ezra | Oct 18, 2005 10:13:21 AM

Okay.... but. I don't (still) get the sense that this "meme" has taken hold in more than a generalized way - a vague perception that Canada's model means long waits and people running here if the wait gets too long. Hard numbers may help address the vague perception, ut they run hard up against an American bias of thinking that our system, when one can afford it, provides some of the best care in the world. If the two think tank (and think tanks, I've never heard of, nor want to) articles overstate, there's still not a lot of data in the study to answer the question - okay, not a lot (or not as many as claimed.. that's not all that clear either) of people come across the border for medical procedures... but who does, and why?

Now about those best hospitals - the article says 11 of 20 responded. It goes on to say that the data collected (from those institutions) was not all they hoped, and was not very conclusive. That sounds worse than a 55% completion rate, at least to me. And so my question remains - do we actually know how many wealthy foreigners opt out of their own systems to come here for care? I suspect we don't and I suspect it's significant and instructive. But that, too, is an assumption, and I agree there are far too many assumptions about the state of American health care and not enough good hard information widely distributed to the general public. Telling them Canadidans are generally pleased with the care they get in Caqnada is helpful in one sense, but what Americans need to undersatdn first is the system they have, not the system that might be better (a fact of which I am still not convinced). It's defining the problem that keeps getting left behind in these lofty discussions of how we can improve American health care, and that's a problem the right (which doesn't want to admit there is a problem) and the left (which doesn't like acknowledging that the problem is vastly more complex than a simple solution) share.

Posted by: weboy | Oct 18, 2005 1:51:43 PM

Ezra,

I specifically didn't claim that the study was wrong, I merely point out that this data can be difficult to get. Maybe they got it right, I would be cautious in implimenting policy based on it though.

the survey on found online, here appears to be the one you are talking about. It is 125 pages, and indicates it is to be used for personal interviews, particularly CATI (Computer Assisted Telephone Interviews.) I have worked extensively on CATI surveys with several platforms, both in a programming and analysis functions. I merely point out some of the difficulties I would foresee in collecting this type of data. Take it or leave it.

Big Pharma is of course very profitable. They do do a lot of marketing. They also do a lot of R&D and save a lot of lives. I few the last as extremely important, and worry about messing with it. Doesn't mean that everything is perfect, but it is something I don't want to 'break.' I wouldn't care to trade the existing drugs we have now freely availible to everyone for the advances we will make over the next twenty years.

Posted by: Dave Justus | Oct 18, 2005 1:52:01 PM

Hey Ezra,

Have you ever considered if universal heath care is doable on the state level. This might be a good way to get the ball rolling as it would give the individual state a competitive advantage and serve as an example for the rest of the country. Obviously you would need a large population (CA, IL, or NY) for the price advantages to kick in.

Posted by: Fledermaus | Oct 18, 2005 10:37:32 PM

The American marketplace pretty much single-handedly funds drug research and development. If reimportation is allowed, one of three things will happen. Either the price in America will drop to the same as it is in Canada (with negative consequences on R&D), the price in Canada will rise to that of America... or... Canada will produce its own drugs violating U.S. patents.

So, let me see if I understand this argument. It goes like this:

1. Sick Americans pay far more for drugs than sick people in other countries.
2. However, this is a good thing: by doing so, sick Americans are funding the R&D that develops these drugs in the first place.
3. However, sick Canadians, etc, pay closer to the marginal cost of manufacturing the drugs.
4. If everyone paid Canadian prices, the drug companies would not be able to fund their R&D, and the supply of new drugs would disappear.
5. So, effectively, by paying high prices for drugs, sick Americans are selflessly subsidising the health care system of the entire world.
6. Yay! Go sick Americans!

Or, to put it another way,instead of paying for pharma R&D through tax-supported public research, the US has decided to allow pharma companies to tax the sick. And the right is supporting this out of an altruistic concern for the health of the rest of the world.
Am I misrepresenting this at all?


Posted by: ajay | Oct 19, 2005 5:21:55 AM

ajay,

Essencially that is true except that I am not sure the term 'tax' applies. I don't support this out of altruistic concern for the rest of the world. I would prefer that other countries paid more for drugs and we paid less than we do. I don't see any way to make them do so however, so that is a somewhat moot issue.

I support the idea that sick Americans (and the government) pay for R&D because I want lots of R&D for drugs. I don't trust a government bureaucracy to be able to channel the money as efficiently as the big Pharma companies do. Yes, I know all the issues about me-to and non lifesaving drugs, but I believe that politically controlled research would be even worse.

Basically, I think we have a horrible system that is better than any alternative.

Posted by: Dave Justus | Oct 19, 2005 10:50:37 AM

Still, I think the major point is that Ezra has come up with hard data that strongly suggests that Canadians are not regularly crossing the border to get a level of health care that is, allegedly, not available in their home country. Now it is fair to question the survey, but until those that feel the study is somehow not telling the whole story can produce something other then anecdote then I think you need to kind of back off the claim since you have no real data.

Posted by: Rick DeMent | Oct 19, 2005 11:29:45 AM

Rick,

I don't make any 'claims' that Canadians are, or are not, crossing the border for medical care. I am sure that some are, but how prevelant that is is hard to say.

We can make a few assumptions though. Those that would engage in this behavior would be wealthier than average or highly motivated by some other factor. The dynamics would be similar to private vs. public schools in the U.S.

This survey of course wasn't really designed to answer that question anyway. It was designed with the 'average' Canadian in mind as much as possible.

I haven't really analyzed the claims about Canadians coming to America. It isn't really that important to me, so I don't care if it is .05% or 10%. Of course that claim would require evidence to back it up, with or without this survey. If there is evidence to back up that claim, this survey would, it seems to me, not be a very effective piece of counter evidence. If there is no good evidence for the claim that large numbers of Canadians are coming here then the evidence from this survey is unnecessary.

Of course the real question wouldn't be whether Canadians are or are not crossing the border, but whether they would prefer (costs being equal) to get health care in America or in Canada if we are to answer the question of whether (costs asside) Canada or America is perceived to have better health care.

Posted by: Dave Justus | Oct 19, 2005 1:32:47 PM

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