Blog: Canada’s single payer system produces better outcomes for CF patients than the US system

An important study was published this week in the Annals of Internal Medicine, “Survival Comparison of Patients With Cystic Fibrosis in Canada and the United States,” by Anne L. Stephenson and colleagues.1  The investigators used cystic fibrosis (CF) registries in the United States and Canada to compare outcomes for these patients between the two countries, and the bottom line made headlines in major media outlets: Canadian CF patients did better—much better—indeed they lived some 10 years longer than US CF patients.  The investigators found 34% lower mortality for Canadian CF patients even after controlling for a wide variety of patient and clinical characteristics, including genotype, an important marker of disease severity.  This difference was demonstrated in multiple subgroup analyses (for instance, when looking only at delta F508 homozygotes).    Moreover, over time, Canadian CF patients saw greater improvements in life expectancy.  Finally, they were also more likely to receive organ transplants.

Thus, despite the often-vaunted superiority of the American healthcare system, here is yet another piece of evidence that single payer public systems can deliver better results—indeed in this case the Canadian system even provided more high-technological care (i.e. transplants), which is supposed to be our specialty.

There is one additional finer point to make.  When examining US CF patients by insurance status, the investigators found that those with private insurance did not do significantly worse than Canadian CF patients, whereas the uninsured and those with Medicare/Medicaid (treated as one category) did.  Does this somehow provide evidence that private insurance is superior to public insurance, or does it weaken the overall point that the Canadian single payer system better served CF patients?  No, for a number of reasons.  First, Medicaid, as important as it is, does in fact sometimes provide a lower tier of access to medical care:  for instance, CF patients with Medicaid are less likely to be accepted for a lung transplantation in the US.2  Thus, even apart from the possibility of residual confounding given the association of Medicaid with lower socioeconomic status, it would not be surprising to find worse outcomes for those with Medicaid as compared to those with private insurance in the US.  Second, it is hard to use this study to say much about Medicare.  In part, this is because subjects with Medicaid and Medicare were combined into a single group, so it’s unclear which (or both) of these populations were driving the finding.  Additionally, those under 65 can only get Medicare if they are disabled.  Comparing this disabled CF population to a general Canadian CF population would leave the door open for residual confounding.

  1. Stephenson AL, Sykes J, Stanojevic S, et al. Survival comparison of patients with cystic fibrosis in canada and the united states: A population-based cohort study. Annals of internal medicine 2017.
  2. Quon BS, Psoter K, Mayer-Hamblett N, Aitken ML, Li CI, Goss CH. Disparities in Access to Lung Transplantation for Patients with Cystic Fibrosis by Socioeconomic Status. American Journal of Respiratory and Critical Care Medicine 2012;186:1008-13.

Blog Post, St. Patrick’s Day Edition: What’s going on with universal health care in Ireland?

In recent years, several nations have announced bold plans for sweeping universal health care reform. One of these is India, which, as it has turned out, has done basically nothing to achieve that goal under the BJP government of Narendra Modi. However, as today is St. Patrick’s Day, I’ll discuss the case of Ireland, which hasn’t made much progress either.

A recent article in the journal Health Policy (“From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis”) by Sara Ann Burke and colleagues at the Centre for Health Policy and Management at the Trinity College of Dublin School of Medicine explains this well. It’s very much worth reading (and is open access!). It traces the trajectory of “universal health care” reform in Ireland over the past 5 years. In what follows, I’ll summarize some of the main points of that article (interspersed with my own commentary) to give a sense of the health care scene in Ireland.

In 2008, Wall Street sunk and, as we all know, took the global economy down with it in the process. Recession brought about the era of austerity in Europe, and this had the effect of starving health care systems throughout the continent. Ireland was one of the nations facing fiscal and health system austerity. Nonetheless, as Burke et al. note, the 2011 election in Ireland put a new coalition government into power that declared the goal of achieving universal health care. Why was this necessary? Don’t all high-income nations except the US already have “universal health care”? Well, not exactly.

Ireland, for instance, has long had a “two-tier” public-private health care system, as Burke et al. describe. A public system, they note, which goes by the name of the “General Medical Services” (GMS) scheme, covers a substantial minority of the population: these low-income individuals get free GP services as well as low cost prescription medications (those without GMS coverage, on the other hand, have to pay more than €50 for a primary care visit). However, as they emphasize, almost half of the population is covered through private health insurance, a benefit that gives them superior access to hospital care.1

Now, as they note, the government’s 2011 plan for universal health care called for a level playing field, which sounds like a step in the right direction. However, this wouldn’t be through single payer transformation, but instead through a Dutch-style reform, with everybody mandated to purchase a plan from a for-profit private health insurance company.2

However, the Dutch approach has serious shortcoming, as I recently wrote about in Jacobin. I noted the following, in describing some of the parallels between the Dutch reform and the Affordable Care Act:

If the Netherlands model demonstrates anything, it’s that some forms of “universal” health care are less worthy of emulation than others. Expanding access the Dutch way (itself based on US policy ideas) would leave intact much of the waste of the current system — without achieving the equity implied by the term ‘universal health care.’

To be fair, as Burke et al. describe, the Irish government was also proposing that everybody would at least get free GP visits under the reform, which would no doubt be a significant and meaningful improvement. Regardless, basically none of this came to pass. As they describe, the last five years have seen no major change in health insurance coverage in Ireland: the percentage of the population with GMS cards saw no major change, while some evidence pointed to a rise in wait times. At the same time, they state, the government retreated from its previous calls for “universal health care” and free GP visits for all (it did expand free GP visits to those > 70 and those < 6, though that was about it).3

They thus conclude:

While there has been an intent of universalism in official government policy since 2011, the data presented here show little progress made on increasing the breadth, with decreasing depth and scope of coverage of coverage evident through increased user charges and numbers waiting for hospital diagnosis and treatment. The exception is the extension of free GP care to the youngest and oldest citizens in mid-2015 and a small increase in private health insurance in 2014/5.   This failure to progress towards universalism can be explained by the unrelenting pressure on the health system as a result of budget cuts since 2009 and by the lack of clarity on the exact form of universalism espoused and the mechanisms to achieve it.4

This paragraph lays out the problem very succinctly. On the one hand, the system was hard pressed by the financial demands of austerity. Others have emphasized the effect of austerity on health care in Ireland: at a time when people needed more protection, not less, coverage fell while copayments (“user fees”) rose. Here is Alexander Kentikelenis, for instance, in the European Journal of Public Health:

Ireland also implemented steep health sector cuts in 2012 as part of the fiscal adjustment programme agreed on with its international creditors, and introduced a rise in user fees. The onset of austerity marked a reversal in the extent of coverage, and tightened eligibility criteria for issuing [GMS] ‘medical cards’—a means-tested programme for the poor—resulted in the decline of people covered under this programme.5

And on the other hand, Burke et al. note that the “exact form of universalism” being pursued was unclear, which is exactly right: unlike a comprehensive national health insurance or national health system reform, the government, they suggest, envisioned a system run by private insurers as in the Netherlands or, to an extent, in the US.

However, even that reform didn’t come about. Ireland, like the US, as a result still lacks true universal health care, with equitable access to all. Looking ahead, Burke et al. write,

Ireland is at a critical juncture, veering between a potential path to universal healthcare and a system overwhelmed by seven years of austerity, which continues to maintain the status quo and a historical bias towards a two-tier unequal system of care.6

Unfortunately, people in nations throughout the globe are contending with similar problems: inadequate funding and unequal health system access. But private health insurance – whether dubbed “universal” or not – is not the answer, either for Ireland or the US.

 

Notes

1 Burke SA, Normand C, Barry S, Thomas S. From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis. Health policy 2015. In press.

2 Ibid.

3 Ibid.

4 Ibid.

5 Kentikelenis A. Bailouts, austerity and the erosion of health coverage in Southern Europe and Ireland. European journal of public health 2015;25:365-6.

6 Burke SA, Normand C, Barry S, Thomas S. From universal health insurance to universal healthcare? The shifting health policy landscape in Ireland since the economic crisis. Health policy 2015. In press.