Universal Health Care: Experiencing Canada and the USA

Here is an interesting discussion about Melissa, a Republican who had to move to Canada and changed her mind about Universal Health Care after experiencing it. She also discusses abortion policy in Canada a little bit. In a separate post Melissa describes why she used to fear Universal Health Care.

The comments on the first piece are interesting, too. Many sound like they learned something. There are a number of Canadians showing up to gloat (we love talking about how great our health care is). But this is probably the saddest comment I read there:

I am not in favor of Universal Health Care on principle. it all sounds so good, but you are giving your freedom of choice completely away. The government becomes your provider, not God. You become dependent on the government and worship it instead of God.

I don’t think Obama care is the solution. Government taking away from some to give to others is not charity is stealing. you can’t force charity on people. God doesn’t do it, why should government or anyone do it??

on the surface, UHC looks good, but it’s a web of deceit.

PS I don’t have insurance and I pay cash for all my health care. I have 4 children.

This outlook is very unfamiliar to me.  I think this (anon) commenter is wrong about giving your freedom away: we have lots of choice in Canada. But the idea that the government replaces God? That is what seems unfamiliar to me. I don’t see how a company providing insurance doesn’t replace God in the exact same way.

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Cancer Treatment Centers of America: Hope, But Don’t Hope

I often see these commercials for the Cancer Treatment Centers of America, and I find them misleading and unethical. I can’t seem to embed the video, but it can be found at this link. Most of their commercials are all about giving the patient “hope” where there was no hope before. But each commercial also carries a disclaimer: “No case is typical. You should not expect these results.” So the CTCA are suggesting that you should have hope and that they will offer you hope when other MDs fail to do so, but that you should also no have hope that it will work for you (although here “hope” is replaced with “expect”).

You need more than a second opinion. You need a second chance.

1. Legal Reasons for Disclaimers in Medical Advertisements

The reason for the disclaimer results from a lawsuit in the 1990s:

Cancer Treatment Centers of America was the subject of a Federal Trade Commission (FTC) complaint in 1993. The FTC alleged that CTCA made false claims regarding the success rates of certain cancer treatments in their promotional materials. This claim was settled in March 1996, requiring CTCA to discontinue use of any unsubstantiated claims in their advertising. CTCA is also required to have proven, scientific evidence for all statements regarding the safety, success rates, endorsements, and benefits of their cancer treatments. CTCA was also required to follow various steps in order to report compliance to the FTC per the settlement.

Cancer centers and hospitals in general (including Cancer Treatment Centers of America) have been the subjects of some controversy over their advertising. Many doctors and other observers have noted that many cancer organizations’ advertising are sparsely regulated and, therefore, often contain unsupported and misleading claims as to the efficacy of their cancer treatments.

In 2001, the FDA issued CTCA a Warning Letter concerning three clinical trials that were conducted in violation of FDA requirements. (From Wikipedia)

I understand that there are legal reasons for the disclaimer. Nevertheless, I find it creates an odd message overall. It also illustrates some of the problems with advertising in medicine.

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The Founding Fathers’ Individual Mandate for Health Insurance

Yesterday in the USA, Federal Judge Roger Vinson ruled that the individual mandate was unconstitutional (the whole opinion is here), and so ruled the entire health care law is void:

Because the individual mandate is unconstitutional and not severable, the entire Act must be declared void. This has been a difficult decision to reach, and I am aware that it will have indeterminable implications. At a time when there is virtually unanimous agreement that health care reform is needed in this country, it is hard to invalidate and strike down a statute titled “The Patient Protection and Affordable Care Act.” (pg. 76)

One thing raised in the ruling is whether the individual mandate is unprecedented:

Congressional Budget Office Memorandum, The Budgetary Treatment of an Individual Mandate to Buy Health Insurance, August 1994 (“A mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action.”) (“CBO Analysis”). Never before has Congress required that everyone buy a product from a private company (essentially for life) just for being alive and residing in the United States. (pg. 38)

Judge Roger Vinson rightly notes that the mere fact that a law is unprecedented does not necessarily mean that it is unconstitutional, but, he writes,  a lack of previous similar legislation might nevertheless count against the presumption that a law is constitutional:

As I explained in my earlier order, the fact that legislation is unprecedented does not by itself render it unconstitutional. To the contrary, all federal legislation carries with it a “presumption of constitutionality.” Morrison, supra, 529 U.S. at607. However, the presumption is arguably weakened, and an “absence of power” might reasonably be inferred where — as here — “earlier Congresses avoided use of this highly attractive power.” Printz v. United States, 521 U.S. 898, 905, 908,117 S. Ct. 2365, 138 L. Ed. 2d 914 (1997); id. at 907-08 (“the utter lack of statutes imposing obligations [like the one at issue in that case] (notwithstanding the attractiveness of that course to Congress), suggests an assumed absence of such power”) (emphasis in original); id. at 918 (“almost two centuries of apparent congressional avoidance of the practice [at issue] tends to negate the existence of the congressional power asserted here”).

The mere fact that the defendants have tried to analogize the individual mandate to things like jury service, participation in the census, eminent domain proceedings, forced exchange of gold bullion for paper currency under the Gold Clause Cases, and required service in a “posse” under the Judiciary Act of 1789 (all of which are obviously distinguishable) only underscores and highlights its unprecedented nature.  (pg. 39)

Does that mean that if there were a previous law that imposed similar obligations, then the presumption that the law is constitutional would be strengthened?

Because Rick Ungar uncovered a precedent from 1798 “An Act for the Relief of Sick and Disabled Seamen.” Ungar writes:

In July of 1798, Congress passed – and President John Adams signed – “An Act for the Relief of Sick and Disabled Seamen.” The law authorized the creation of a government operated marine hospital service and mandated that privately employed sailors be required to purchase health care insurance.

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Abortion Access in Canada

I recently found the article, “Who Decides?” by Scott Lemieux via a post on Figleaf’s blog (I left a comment there and this post is a modified version of that comment).

Lemieux muses about abortion access in Canada:

In Canada, late-term abortions are not legally restricted, and Canada also doesn’t have the other kinds of restrictions found in many American states and doesn’t exclude abortion from guarantees of health care. As far as I can tell, there’s no evidence that Canadian women get late-term abortions at significantly higher rates (and historically overall abortion rates in Canada have actually been lower). Essentially, absent evidence to the contrary, I think the presumption in favor of a woman’s decision-making capacity is justified, and further restrictions are likely to do more harm than good.

I find Lemieux’s musings on what abortion and abortion access might be like in Canada to be highly misleading. Canada does not have the kind of easy access to abortion that Lemieux implies.

Lemieux is right when he says that there are no laws restricting abortion in Canada. But that does not mean there are no restrictions. Most abortions in Canada are done in hospitals (rather than clinics) and hospitals are left to make their own policy regarding abortion. Most hospitals do have policies that restrict late-term abortion access. Hospitals used to set a cut-off of 21 weeks (with exceptions made for mother’s health or foetal health), but recently with advances in prenatal testing (especially prenatal genetic testing) many hospitals have increased this limit to 24 weeks (again with health-based exceptions). In these cases hospital policy does not seem to reflect a commitment to women’s decision-making (after the early period of the pregnancy), instead the policies reflect changes in medical technologies and the dates at which reliable test results become available. Some clinics also place limits on when they will perform abortions.

Second, even though abortions are legal, no hospital or doctor is required to perform them. So Canada also has issues with access when women cannot find a doctor in their area willing to perform an abortion. In some cases this effectively means there is no access. One province (PEI) has no abortion providers at all; and a second (New Brunswick) has virtually no abortion providers. Canada is also a large country with a small population so even in the provinces that do have abortion providers, women in the northern or rural areas of those provinces might not be able to access abortions.

Third, while it is true that abortions are covered under most provincial insurance plans (so they are a part of our guaranteed health coverage, as Lemieux states), abortion is one of the few services that are excluded from reciprocal billing (PDF).  Part of the guarantees made in the Canadian Health Act is that insurance coverage is portable from province to province. This means that if I live in Ontario, I am covered by the Ontario Health Insurance Plan (OHIP), but if I go on vacation to BC and have an accident I can still use my insurance in the BC hospitals. One of the few exceptions to this promise is abortion coverage. Most provincial insurance plans will cover abortion within that province, but will not cover abortions if you travel to another province. Obviously this can cause significant access problems for women in PEI and New Brunswick who cannot find access in their own province. It also limits access to abortion for college and university aged women who go to school outside of their home province. Most students remain covered under their home province, and if they find they need an abortion while in another province they will have to pay out of pocket.

Canada might not have any laws restricting abortion access, but this does not mean that access to abortion in Canada is unrestricted.

I include some links for further reading after the fold.

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