I hate waiting in lines. When I was doing my cardiothoracic residency at Long Island Jewish Hospital in New York, I found that I had to wait for everything. Driving on the Long Island Expressway was usually bumper to bumper and it did not matter what day or time it was. Also, doing the chores of everyday living like grocery shopping or getting a hair cut, would require standing in line for check out or waiting for a barber to become available, and it did not matter whether I waited to do these activities when most people were sleeping or in the light of day. One of the advantages of living in New York City was that you could always find something to do no matter the time; but it was also a disadvantage as there was always a crowd.
Now, with the elimination of the Individual Mandate of the Affordable Care Act (ACA), the prospect of waiting in lines for health care is a new cause of concern.
The key goals of the Affordable Care Act were to increase the number of people with health insurance and decrease the costs of health care overall. Although, more people became insured, the rising premiums and deductibles resulted in more people, especially those who were at lower risk for needing the insurance, to stop buying insurance. With the new tax law just passed by Congress and signed by President Trump, the elimination of the individual mandate makes it more likely that people will forego health care insurance; it stands to reason that more people will opt out of buying high cost health care insurance since they will no longer have a monetary penalty to pay in the form of a tax.
In order for the health insurers to stay viable, they need more healthy people to buy insurance. These people are less likely to ever need to use the insurance and they would be paying premiums that the insurers would use for those who did need to use the health care system. Without healthy people paying premiums for care they would never use, it was foreseeable that insurers would either get out of the business or rely on the government paying them to stay on.
In fact, government supplements were built in to the ACA but, when the Congress switched to Republican control, those supplements were stopped. Without these payments, many health insurers had to leave the business; no one stays in business if they find themselves losing money.
It has been predicted that the ACA would eventually fail due to increasing costs and the abandonment of healthy patients. The fallback plan would then be to push for a single, government paying system. It looks like this plan is coming to fruition but it may not be as good as some claim.
Senator Bernie Sanders has proposed a single payer health care system which is modeled on what is done in Canada. Under this model, people will get health care and the government will pay for it much like it does today for those getting Medicare and Medicaid. The one thing that is downplayed in this system is how scarce medical resources will have to be rationed by price or time.
In Canada, the “free” care provided may require a wait. A recent study by the Fraser Institute shows that waiting times for medically necessary treatments continues to increase in Canada (Waiting Your Turn, Wait Times for Health Care in Canada, 2017 Report). According to the Fraser report, specialist physicians who were surveyed claim a median waiting time of 21.2 weeks between the referral from a general practitioner and the commencement of treatment. This is a long time for someone who has cancer or has significant pain from a medical condition that needs an operation.
Being seen by the appropriate specialist is not the only thing requiring a wait in Canada. Since the need for diagnostic studies exceeds the capacity of the system, people wait about 4 weeks to get a CT scan, 10.8 weeks for an MRI, and 3.9 weeks for an ultrasound. Overall, in Canada over 1 million patients are waiting in line for care based on 2017 data.
Bacchus Barua, the author of the Fraser article states that the long wait times may lead to “increased pain, suffering, and mental anguish.” They can also result in “poorer medical outcomes—transforming potentially reversible illnesses or injuries into chronic, irreversible conditions, or even permanent disabilities.”
Under the Emergency Medical Treatment and Active Labor Act (EMTALA), any person in America presenting to an emergency department must be given a screening exam and, if that exam shows an emergency medical condition or active labor, stabilizing care. No wait times allowed and no referrals to others until the condition is stabilized. There are exceptions allowed under EMTALA but the intent is to provide immediate care regardless of the patient’s ability to pay. The care may be expensive, but it is readily available.
In America, many facilities have multidisciplinary clinics which bring together many specialties where a patient can be reviewed at one clinic visit. For example, a patient with a new lung nodule seen on a chest radiograph may be seen by a pulmonologist and a surgeon in the clinic visit. After the visit, a conference is held where the case is discussed and a diagnostic and treatment plan is made. Multiple pertinent specialists such as oncologists, surgeons, pulmonologists, and radiologist attend the conference. This type of care markedly reduces the time from referral to definitive treatment, but it is obviously expensive as several providers have to commit their time and services.
Free health care sounds like a good idea but those of us in the health care field know that nothing is really free. If the government decides that some care, which may be life-saving, is just too expensive, then they may decide to only provide less costly alternatives. This will leave us with a two-tiered health care system; those who can afford it will either pay out of pocket for their own private care or they will become medical tourists and take their chances for care in other countries. Those who cannot afford to pay for the needed care will just have to wait in line. Canadians can come to America for high quality care. Where can Americans go?
Dr. Weiman is the author of two books, Medical Malpractice and Fundamental Issues in Health Care Law.
Dr. Weiman’s website is www.medicalmalpracticeandthelaw.com