[Congressional Record Volume 140, Number 146 (Saturday, October 8, 1994)]
[Extensions of Remarks]
[Page E]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]


[Congressional Record: October 8, 1994]
From the Congressional Record Online via GPO Access [wais.access.gpo.gov]

 
                ``HOW NOT TO IMPROVE YOUR HEALTH CARE''

                                 ______


                          HON. PETER HOEKSTRA

                              of michigan

                    in the house of representatives

                        Friday, October 7, 1994

  Mr. HOEKSTRA. Mr. Speaker, Dr. Ian Munro's article, ``How Not to 
Improve Health Care,'' which appeared in the September 1992 issue of 
the Reader's Digest, helps to explain why recent proposals for health 
care reform failed.
  I ask that this insightful and prescient article be included in the 
Record.

                 [From the Reader's Digest, Sept. 1992]

                     How Not to Improve Health Care

                        (By Ian R. Munro, M.D.)

       Little Joel Bondy of Leamington, Ontario, was born with 
     heart deformities that restricted the blood flow to his 
     lungs. He needed open-heart surgery--soon--to live. The 
     nearest equipped pediatric facility was the Hospital for Sick 
     Children, four hours away in Toronto. But under Canada's 
     national health-care system, commonly called Medicare, that 
     hospital had closed hundreds of beds. For the remaining 
     stripped-down services, there was a long waiting list.
       After delays, Joel's desperate parents notified 
     administrators they were taking him to a hospital in the 
     United States. Amid embarrassing news reports about the boy's 
     plight, the Hospital for Sick Children gave him an early 
     surgery date.
       But it was too late. Joel Bondy died four hours before 
     surgery was to begin. He had waited nearly two months for his 
     operation.
       Kent Maerz has keratoconus, a disease of the cornea. Last 
     August the 22-year-old Calgary student needed a corneal 
     transplant within a few months to correct his rapidly 
     deteriorating vision. Under Canada's Medicare, the operation 
     would cost his family nothing. But the wait would be two to 
     three years.
       Maerz paid his own way to get a transplant at McIntyre Eye 
     Clinic and Surgical Center outside Seattle, Wash., in 
     February. The travel and the operation cost Maerz's 
     family almost $5000. So far, the Alberta Health Care 
     Insurance Plan has reimbursed them only $644. ``If I had a 
     choice, I wouldn't pay taxes for Medicare,'' says Maerz. 
     ``When I needed it, it didn't do me any good.''
       Today, many Americans believe the U.S. health-care system 
     is dangerously flawed. Angered by the cost of private health 
     insurance, which millions cannot afford, a strong majority--
     69 percent, according to a poll in the Wall Street Journal--
     think the United States should adopt national health 
     insurance.
       Legislation to create a system closely modeled on Canada's 
     has 71 co-sponsors in the House of Representatives and broad 
     union support. Sen. Paul Wellstone (D., Minn.) has introduced 
     a similar measure in the Senate. But before Americans leap to 
     national health care, they should look at how the Canadian 
     plan, perhaps the purest system of national health insurance 
     in the world, really works.
       When a Canadian visits his doctor, the doctor bills the 
     government. If the patient visits a hospital, the hospital 
     pays for his care out of a lump sum of money the government 
     gives it each year, and bills him nothing. That means the 
     government pays in full for all health care--except for 
     voluntary procedures such as face lifts--for every citizen. 
     There is no private health care to speak of, even for the 
     very rich.
       Medicare is popular in Canada, especially among those who 
     have not been seriously ill. After all, it appears to be 
     totally free. In fact, it is very, very expensive.
       The average Canadian already pays 46 percent of his income 
     in taxes. But Canada's health-care spending is growing faster 
     than inflation, faster than its population and faster than 
     the country's gross national product. Today, the United 
     States has the costliest health-care system in the world. But 
     Canada's is second, and both countries' per-person costs have 
     been rising at the same rate for years.
       With Canadian taxpayers stretched to the limit, how has 
     Medicare responded to its runaway costs? It has not delivered 
     the unlimited care it promises. It simply spends less, even 
     when patients need more.




       A Magnetic Resonance Imager (MRI) takes pictures to 
     determine the shapes and positions of tumors. Tennessee, with 
     4.9 million people, has more MRI scanners than all of Canada, 
     with 26.6 million people. ``There's a six-month wait for an 
     MRI,'' says Dr. Walter Kucharczyk of The Toronto Hospital. 
     ``Some patients suffer because of the wait.''
       A lithotriptor uses sound waves to smash kidney stones and 
     gallstones. The United States has more than three times as 
     many lithotriptors per patient as Canada. It also has about 
     three times as many open-heart-surgery and cardiac-
     catheterization-units.
       Under Canada's national health-care system, operating rooms 
     and surgical beds are dwindling. To save money, Canadian 
     hospitals routinely close additional beds and reduce surgical 
     capacity in the summer and around Christmas.
       So patients wait. In Newfoundland the average wait for a 
     coronary-artery bypass is one year.
       To avoid making the critically ill wait too long, patients 
     are ranked. ``Emergent'' cases--like heart attacks and car 
     accidents-require care within 24 hours. ``Urgent'' cases are 
     next in importance. Patients not actually in danger are 
     classified ``elective.''
       But many elective patients, while not dying, are in pain. 
     Kenneth Hill, an orthopedic surgeon in Burnaby, B.C., does 
     hip replacements for arthritis patients. The average wait for 
     this ``elective'' procedure is 27 weeks. But without surgery, 
     some of Hill's patients cannot even get off his examining 
     table unassisted. ``They can survive on painkillers,'' he 
     says. ``But the quality of their lives is impaired, and some 
     don't have many years left.''
       Moreover, getting classified ``urgent'' doesn't necessarily 
     speed treatment. On Saturday, August 25, 1990, a CAT scan 
     revealed a mass in Stanley Roberts's brain. If the mass was 
     an abscess, it could kill within days.
       On Monday Roberts's doctors decided he needed an ``urgent'' 
     stereotactic biopsy to diagnose the mass. But the nearest 
     equipped hospital, Vancouver General, had shut down 13 
     neurosurgery beds for the summer and could not take 
     Roberts until the following Tuesday--eight days later. 
     With Roberts visibly deteriorating, his desperate son 
     pleaded to speed things up. But the hospital would not 
     open an operating room after hours and incur overtime 
     costs for staff. By Friday, Roberts was dead of an 
     abscess.
       In the United States, admits Dr. Alan Hudson, president and 
     CEO of The Toronto Hospital, ``you'll get your X ray tomorrow 
     and your operation the next day, and they'll apologize that 
     they can't do them both right now.''
       Small wonder that many sick Canadians head for the border. 
     In 1990, half the lithotripsies performed at Buffalo General 
     Hospital in New York--602--were on Canadians. Even government 
     officials seek care in the United States. When Quebec Premier 
     Robert Bourassa developed a cancerous mole, it was removed at 
     the National Cancer Institute in Bethesda, Md.
       Border-crossing can help rich or desperate Canadians. But 
     it cannot ultimately solve these other problems of Canadian 
     Medicare:
       1. Overuse. Because it's free, Canadians visit doctors' 
     offices almost twice as often as Americans. The cost is 
     driving taxes up and Medicare under.
       Dr. William Weaver of Vancouver sees patients who roam from 
     doctor to doctor seeking prescriptions for narcotics, at no 
     cost to themselves. William Rudd, a colorectal surgeon in 
     Toronto, was recently the 24th doctor a patient consulted for 
     the same complaint. The malady? ``An emotional disease, 
     projected onto the body,'' says Rudd. ``But the exam cost 
     $110. Multiply that by 24 times and tens of thousands of 
     people!''
       Abuse of emergency rooms--expensive to run but free to 
     use--is rampant. Doctors complain about parents who appear at 
     night with children who have colds, because it is 
     inconvenient to see a doctor during the day. Some non-urgent 
     patients arrive at emergency rooms in ambulances. The 
     ambulance is free; taxis charge a fare.
       ``The problem,'' says Weaver, ``is the foolish generosity 
     of the system.'' Dr. Joan Charboneau, of Mississauga, 
     Ontario, agrees: ``If something appears to be free, people 
     don't feel responsible for how they use it.''
       2. Special access. One of Medicare's proudest boasts is 
     ``equitability.'' The system is supposed to guarantee that no 
     Canadian gets better health care than any other. But some 
     irate Canadians say equitability is a sham. ``Bureaucrats, 
     politicians and senior businessmen jump the queues by phoning 
     hospital administrators,'' says David Somerville of the 
     National Citizens' Coalition. ``It not even illegal; the 
     hospital just says they're `urgent.'''
       Then there's the National Defense Medical Center (NDMC), a 
     244-bed hospital in Ottawa run by the Canadian military. 
     Theoretically, it serves the armed forces. But according to a 
     report by Auditor-General Ken Dye, 61 percent of its patients 
     were nonmilitary--including members of Parliament, diplomats 
     and senior bureaucrats.
       NDMC has its own CAT scanner and a nationally renowned 
     cardio-pulmonary unit. It is the only hospital in Ottawa 
     equipped with a helicopter pad. ``I don't think we'll get 
     fundamental reform until those with the power to make changes 
     feel the pain of the system themselves,'' Somerville says.
       3. Patients mattering less and less. Dr. Charles Wright, a 
     manager at Vancouver General Hospital, says administrators 
     maintain waiting lists on purpose, the way airlines overbook. 
     As for urgent patients on the lists who are in pain, Wright 
     argues that ``the public system'' will decide when their pain 
     requires case. These are ``societal decisions,'' he declares. 
     ``The individual is not able to decide rationally.''
       A patient at a Canadian hospital doesn't pay for his stay, 
     nor is it paid for by his own insurance. Each patient is a 
     drain on the fixed budget the hospital gets from the 
     government. For this reason, Canadian hospitals have no 
     financial incentive to offer good service. In fact, to save 
     money, many rush, delay or shortchange care--deliberately.
       In 1989 Ontario began opening mammography screening clinics 
     for all women over 50. It was suggested that radiologists 
     evaluate 100 mammograms per hour. Twenty per hour is normal. 
     When radiologists protested, the suggestion was dropped. 
     However, the fee per mammogram was reduced by almost half, so 
     the pressure to ``read'' faster remained. ``Would they want 
     their mothers' mammograms rushed?'' asks one radiologist in 
     disgust.
       4. Demoralized doctors packing up and leaving. I'm 
     originally from England, which nationalized health care in 
     1948. By the time I was in medical school in 1960, an English 
     child could wait two to three years to have his tonsils 
     removed--and I knew I couldn't stay.
       The first legal foundations of Medicare in Canada were not 
     laid until 1965, the year after I emigrated. Another ten 
     years would pass before Medicare began undermining medicine. 
     In 1971 I joined Toronto's Hospital for Sick Children, one of 
     the finest pediatric hospitals in North America. ``Sick 
     Kids'' had 800 beds and no waiting lists. The equipment was 
     superb. But in the mid-1970s the government's influence over 
     health care intensified. By the mid-1980s, Sick Kids had only 
     630 beds. (Today it has 511.) My outpatients were waiting 
     three months for CAT scans. I wanted to do research, but it 
     was impossible to get the money. I could no longer do the job 
     for which I was trained. In 1986 I left Canada for the 
     Medical City Dallas Hospital In Texas, where I am today 
     pursuing my research and performing surgery.
       Across Canada, frustrated doctors are leaving. In 1990, 
     despite tight visa rules, 8263 Canadian doctors were 
     practicing in the United States. Since visa rules were 
     loosened in April, that number is expected to rise sharply.
       Some come to the United States seeking more money. Others 
     want access to facilities and technology. Virtually all are 
     convinced, as I was, that they can no longer deliver 
     appropriate care in Canada.
       It will be a sad irony if America adopts the Canadian 
     system. In fact, Canadian officials are talking about moving 
     away from national health care--charging patients fees for 
     using emergency rooms and doctors' offices, for example, and 
     limiting coverage for the wealthy. ``The system is getting 
     worse day by day,'' says Dr. William Goodman of Toronto. 
     ``America is now where we were 35 years ago--and you're 
     making all the same mistakes.''
       When an individual's medical expenses become crushing, most 
     people believe their government should step in. But to 
     nationalize all health care as Canada has done would be to 
     toss our system out of the frying pan and into the fire. 
     Patients must be free to make their own arrangements with 
     their own insurers and doctors, or there is no hope for 
     American health care.
       In the words of Toronto Globe and Mail columnist Terence 
     Corcoran: ``You can believe that socialized medicare is the 
     most moral system in the world if you want. But the fact is 
     that socialized medicare will not work.''

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