William,

First, I am very glad to read that your wife is responding well to treatment. That's the most important thing, and I pray that she remains well.

Alas, you would likely find a similar situation to your story in Canada. Not having to lose your job to get treatment, per se, but just replace "my insurance" with "Alberta Healthcare" (or the provincial system of your choice) as the entity that you would have to leap through the hoops to get your medication request processed. And add into the mix a waiting list to see a specialist if the family doctor couldn't prescribe it directly. And the inevitable argument between brand name versus generic products and the province willing to provide only the cheaper option.

One of the guiding principles of Canadian healthcare is universality, the premise that everyone pays their taxes into the system and gets the same level of treatment regardless of income or how much tax paid. Now, of course, we know that's a fib: Hockey players and Members of Parliament rarely have to wait for treatment, and those with means opt to go for treatment in the United States rather than sit on a waiting list in Canada. But still, on its face, universality is a strong guiding principle. And of course, in practice, it leads to some rather silly decisions.

For example, the five-year hip. This may have changed in the last couple of years, but back when my wife was practicing in Canada, for those needing a hip replacement, Canadian Medicare would only pay for a five-year hip. That's how long it's rated to last and they buy them in bulk to get the best price. Now, let's say you are a relatively young person getting hip surgery -- say, in your 60s -- and based on actuarial tables you expect to live at least another 15 years. So, you'd rather have the 15 year hip or the 25 year hip, to avoid more potential operations down the road. No, Canadian Medicare only pays for the five-year hip. Okay, you say, how about I pay the difference between the cost of the five-year hip and an upgraded model? Same operation, just an upgraded piece of metal and (bonus!) potential costs savings down the road from not having to do more surgeries. Sound good? No, Canadian Medicare only pays for and only provides the five-year model.

So, because of universality, with Canadian Medicare you have no option but getting the five-year hip and going into surgery to get it replaced when it wears out. Or, if you have means, you can cross the boarder into the US and get whatever you want.

This is what gets lost in the debate. People are unhappy their insurance costs so much, but they don't go the next step and investigate WHY it costs so much. The major cost drivers are services and treatment. You cannot decrease demand for services and treatment in the short-term, so the only way you control those costs are to restrict services and/or restrict treatment options.

I lived through it in Alberta back in the 1990s with the Province going through an economic recession due to declining oil prices -- Alberta is like Texas: oil and cattle -- and the government sought to cut healthcare costs. An advertising plan asking people to reduce their visits to doctors (demand side) actually increased visits. So instead the Provincial Government decided to control costs on the supply side by restricting services. Waiting lists for specialists grew longer, hospital beds were cut (people were literally on stretchers in emergency for days because rooms were not available), doctor reimbursement fees for patient visits were cut (while costs for providing services continued to climb) and prescription options were de-listed. And, it goes without saying, Alberta Medicare premiums (i.e. taxes) continued to increase.

As a good Canadian, its part of my DNA to believe the there should be a social safety net to save people from falling through the cracks. There should be a floor of healthcare services that no one falls below. But with universality, the Canadian Medicare system also provides a ceiling that you cannot rise above (unless you have the money to opt out and go south to the United States for treatment). Having finally finished reading the Senate Bill -- and now looking forward to reading the reconciliation package -- it remains to be seen what system we're about to have delivered here in the United States.

Mike O'Brien wrote "...other than the fact that most Candadians are better dressed and have better manners than America, and a slight accent, you CAN'T TELL THE DAMN PLACES APART."

Actually, everytime to go back to Canada I'm struck by green and empty it is. And this is coming from a guy who how now lives in heavily-forested rural Northern California.

On a more serious note, the major difference is a mindset. There used to be an old joke that kids in the US wanted to grow up to become businessmen while kids in Canada wanted to grow up to work for the government, but there is a germ of truth to the wag. America is about Life, Liberty and the Pursuit of Happiness (note only the pursuit) while Canada, written clearly in the founding document of Confederation, the British North America Act, is about Peace, Order and Good Government.

Just compare those two statements for a moment, and that should tell you all you need to know about the differences north and south of the 49th parallel. 

QUOTE: I am going out this weekend campaigning for a local republican

Time to turn in your commie membership card, Jodi!

Bottom line - before and after this bill passes, if you have a bag of cash and you want to pay a doctor for a service, you're totally free to.

This bill won't change that - the focus is on the health insurers, not the doctors. In fact, in a perfect world, we wouldn't need insurance - we'd go in and pay for the treatment when needed.

But it costs too much. You are also right to look into that - why does it cost so much? Well, tons of reasons, mostly legit and that is what it is, but that's also where something like insurance can be a good thing. I'm ok with paying into a fund each month if I know I'll get something back from it. And such a fund - for something as essential as health care - shouldn't be left to the whims of greed and chasing bottom lines.

Let's take a look at the history of Health Insurance - when Henry J Kaiser opened his shipyards in Richmond California, he partnered with Dr Sidney Garfield, who worked as the facility doctor. Garfield suggested that each employee put in twenty five cents from each paycheck, and in turn, when ever they needed medical care, they just came and got it and didn't have to pay anything.

So far so sweet, right?

Tragically, later, in the 1970s, Kaiser, as a health care organization, made a bit of a bad turn, and helped create our modern system of HMOs - this in a response to the rising health care costs - the rates rose at a normal level till 1967 - when the rate of cost shot up over 100% and kept climbing. Suddenly taking a quarter from each check wasn't going to cover it; a better insurance plan needed to be worked out.

In all fairness to Kaiser, they have since proved to be more reasonable, but they also have a unique situation - they are both a health care organization, as well as an insurance. It's like you're a ship-yard working working on Henry J's lot in Richmond - you're paying into the fund, but if you want service, it's there for you - paid, since Kaiser has their own organization. You go from dept to dept, without referals or pre-auths. It's pretty awesome.

(Full disclosure - I spent a number of super happy years working for Kaiser - it's an awesome organization. I was really proud of the following recent developments: One, Obama noted, a few months ago, that he thought Kaiser had the best set up for health care. Two: Kaiser just last month finally finished their complete EMR installation - they are 100% online - no paper charts or records anywhere in the KP system. It's the biggest EMR in America, perhaps the world. I'm very proud to have worked on that project.)

Anyway - I think we'd do better with more systems like Kaiser - where the insurance is in-house, and not some third party nightmare. I don't know. It's a thought.

But like, there are subtle differences - you have Tim Horton, we have... everything else. Your cheeseburgers are delicious. Ours are usually one USDA grade away from poison. Etc.

But my point is - there's no bread-lines, people aren't starving. It looks like, basically, no offense - MORE America, you know?

Like, when you cross the border south, to Mexico, it's different. The buildings are different, the language is different, etc, but Canada? Just seems like another state. So, clearly the Canadian system isn't causing any destruction of life or society.