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A Real Problem with Healthcare is Access, Not Just Insurance
Everyone talks about the health insurance crisis in America, but rarely do we talk about the other crisis: people with decent insurance coverage who simply cannot access healthcare. There’s more to this than single payer versus private coverage. Health insurance is meaningless if patients cannot actually obtain timely medical care.
This week I helped a friend access healthcare in America. She has health insurance from a national provider. She is a recent legal immigrant (to America, from a place with good national health care) but had little idea how access to a doctor here actually works. She had come down with a terrible case of shingles, spread across her face and back, and moving toward her eye. But she had no primary care physician. After three ER visits she still had no referral. The emergency room dispensed only minimal pain medication and told her to find a primary care physician on her own. None she called would accept new patients before a six-week wait. We finally, using a combination of sweet talk and some advanced begging, found a rare doctor willing to put the patient ahead of the paperwork. She recovered.
For many Americans, the challenge is no longer only paying for health care but finding a clinician who is available to provide it in a timely manner. According to the Centers for Disease Control 10.6 percent of insured U.S. adults could not obtain an appointment when they needed medical care in the previous year, unrelated to cost or insurance. Some 4.6 percent could not reach providers during open hours because of work or caregiving. About 4.4 percent could not find a physician compatible with their insurance, while 2.4 percent said providers were too far away. The latter is a critical issue in rural America and across the bulk of America that has little-to-no public transportation. All those figures above exclude people who never seek care because they cannot afford the deductible their insurance requires.
Maybe it is time to move to Canada. Two acquaintances just immigrated there after a multi-year screening process that included producing original college and high school transcripts, taking a health exam, taking a French language test, interviews, and forms, lots of forms. They needed to hire lawyers to get them over a few humps but ultimately made it. Their motivation resonates strongly: they want decent health care.
I don’t want to break bad news to the newly-minted Canadians, though they have likely already found out for themselves about the problems of accessing healthcare in their new home. Canada’s largely taxpayer-funded system provides universal coverage for medically necessary physician and hospital services, but coverage does not necessarily translate into access. More than in America, 17 percent of Canadian adults do not have a regular family doctor. Some 77 percent say it is not easy to obtain care on evenings, weekends, or holidays. Emergency rooms are overcrowded as a result, in part because 15 percent of ER visits could have been treated in primary care if it was available (a problem America shares because the homeless and others uninsured use the ER as their only doctor). The more specialized the health need up north, the longer the wait. Some 36 percent waited three months or longer for an initial specialist consultation. The median wait from a primary care physician referral to treatment is 30 weeks. At least they do not face the risk of bankruptcy from a medical emergency.
What is a Canadian, already paying for health insurance via taxes, to do? There is no one good answer. Some relief is found among the approximately two-thirds of Canadians who pay for private health insurance on top of the mandatory national kind. That private insurance, except in Quebec, primarily covers only services outside the universal provincial health plans, such as prescriptions, dental and vision care, and other supplemental benefits. It generally does not purchase faster access to medically necessary physician or hospital services covered by the public system. Other sick people resort to private clinics and pay in cash. A lucky few use employer-paid executive health programs. A few even resort to travel to the United States and pay cash directly for specialist care to avoid potentially dangerous waits. These work-arounds reflect a fundamental reality of Canada’s health care system: the principal barrier is usually access, not insurance coverage, as in the United States.
Many of the reasons for these access problems are similar in the U.S. and Canada. They include population growth outpacing growth in primary care providers, retirements among the baby boom docs, and increased demand from an aging population. Additionally, doctors in America face the additional burdens of insurance prior authorizations and processing claims through the specific system each insurance company requires so they get paid. There is also a problem training more doctors in the U.S. to meet demand. Medical education slots face limits because the federal Balanced Budget Act of 1997 capped Medicare funding for residency positions, which hospitals rely on heavily to pay for that training. Congress froze the number of funded residency slots (GME; at a cost of some $21 billion) based on 1996 levels. The number of new slots trails the rising need for doctors. American doctors also face the problem of malpractice lawsuits at roughly five times the rate seen in Canada. In addition to paying out for expensive malpractice insurance, American doctors must also practice defensive medicine, care and tests ordered primarily to minimize the chance of getting sued. This reduces physician capacity.
If you’re looking for solutions (or planning on emigrating somewhere) the place to look might be Denmark. Denmark has a tax-funded, universal health care system in which nearly all medically necessary physician and hospital services are provided without charge. Funding comes mainly from national taxes. Most Danes do not receive their primary health insurance through an employer, and unlike Germany or the Netherlands, they do not generally pay mandatory health insurance premiums to a sickness fund or private insurer. To work around the access problem, about one-half of Danes have voluntary private health insurance. Unlike in Canada, this coverage is allowed to provide fast access to private hospitals and specialist consultations without some of the delays of the public system. It supplements rather than replaces the public system as it grows. Denmark also helps ameliorate the access problem by assigning almost every person in the country (over 99 percent) a primary care physician. There are still problems with a lack of doctors, especially since Denmark made the decision to greatly open its borders to large numbers of immigrants, and it can be hard to switch doctors from the one you are assigned to use. Denmark solves the access problem not by abandoning universal care but by allowing supplemental private care. Denmark demonstrates that universal coverage and private alternatives need not be ideological opposites.
This is where someone asks how much it all costs. It is a complex question, given the cost of the variety of health insurance plans with their varying deductions and provided services in America, plus a very messy tax code that almost ensures no two Americans pay the same amount of tax. With the danger of over-simplifying things, but to try and bring some clarity to all this, OECD calculations set the average tax wedge Americans and Canadians pay at about 30 percent. For Denmark, the same OECD study shows a single worker earning an average wage faces a tax wedge of 36 percent. But in return Danes get free universal health care, free public schools and universities, pensions, generous unemployment insurance, child care and family benefits, and elder care. Americans and some Canadians pay for all of those things in addition to taxes.
We have spent decades in the U.S. arguing over how to pay for healthcare. Increasingly, the question is instead whether anyone can actually access it. America, alongside Canada, supposedly has some of the most advanced healthcare available in the world; too many people just can’t use it. Coverage under any system is not the same as access.
Copyright © 2024. All rights reserved. The views expressed here are solely those of the author(s) in their private capacity.
Trump Wants Free Green Cards for Every College Grad
In a move which both is self-defeating and which exposes the fundamental problem with America’s immigration system, Donald Trump proposed “automatically” giving green cards to foreign nationals who graduate from a U.S. college.
A Trump spokesperson clarified the offer to include both two-year and junior colleges, and to include every foreign student except those who are “communists, radical Islamists, Hamas supporters, America haters, and public charges.” Trump said this was another “Day One” plan for him. The goal is to “to keep the most skilled graduates who can make significant contributions to America.” Currently foreign national college grads have to either leave the U.S. after graduation, work for two years as “practical trainees” and then depart, or apply for a hard-to-get work visa/change of status.
The plan of course is self-defeating on its face. Trump, like most people who read it, thinks his plan will scoop up the PRC MIT A.I. PhD with the 4.0 GPA who wants to work for NVidia, forgetting America’s college system includes pay-for-play schools, visa mills, aimed directly at foreigners who just want a student visa to allow them to work in the U.S., at whatever job. Trump also forgets perhaps his own college days, which must have included a kid who just barely got by and graduated with a C- average in Medieval Music Theory. Not much demand for that, from American or foreign grads. Once again, in order to get the baby America is drinking the bathwater, too.
The concept of a merit-based system in the U.S. is not new. Trump 45 flirted with the idea but never moved to implement it. Even Hillary Clinton proposed a plan to link college grads to green cards. Since 1965 the American immigration system has been tied to the concept of family unification, with little interest paid to anything merit-based. The core problem with the family reunification system is the primary qualification to immigrate legally is simply that family tie. So America gets the drunk brother alongside the nuclear physicist sister. It’s a crap shoot. There is no connection to America’s economic needs. You get the nuclear physicists from Stanford but you also get the drunk modern art appreciation majors from Podunk U. Things work similarly at the border, where America gets whomever survives the Darwinian slog through Mexico. The family reunification system is a legal hangover, as would be Trump’s plan to gift each college grad with a green card.
The American family unification system, with its small number of merit-based visas tagging along (mostly in the H-1B category) is near unique in the industrialized world. Britain, Canada, Australia, and New Zealand use primarily a merit system based on “points.” Based on national needs, an applicant with no relatives in Canada will accrue points based on education (Canada awards 135 points for a Master’s, only 30 for a high school diploma), language ability (extra points toward immigration up north if you are fluent in English and French), and job skills. But you may not need a master’s in computer technology for Canada: they’ll take you if you’re a quantum engineer, but they’ll also take you if you are a tar sands miner willing to live five years in the unsettled west. The key is tying merit-based points to the nation’s economic needs.
The U.S. is stingy with the merit-based visas it does offer. Out of a total legal immigrant pool of about one million, the annual cap for the 2023 fiscal year was 65,000 skilled worker visas, plus only an additional 20,000 visas for foreign professionals with a master’s degree or doctorate from a U.S. institution. However, not all H-1B visas are subject to this cap. For example, up to 6,800 visas are set aside each year for the H-1B program under the U.S.-Chile and U.S.-Singapore free trade agreements. Something special about skilled people in Chile compared to, whatever, Columbia? Back to that baby and his bathwater.
Through the end of the 19th century, America essentially had no immigration law. The country was huge, land was available for the taking, and the need for unskilled workers seemed bottomless. The waves of Germans, Irish, Jews, and Italians came from every dump across Europe and beyond. They entered an America where New York City was a center of light manufacturing and the source of more than half of all ready-made clothing, and the vast Midwest was blanketed with farms and steel plants hungry for workers. This system gave way as the first real immigration laws, targeting the Chinese, who were no longer needed to build the railways out west. Following WWI, Italians and eastern European Jews, who were considered “inferior,” were banned. Racism played a significant role, but it dovetailed more than coincidentally with an economy that was shrinking (ultimately, the Great Depression) and demanding more skilled workers.
The years following WWII saw a massive change in immigration law. In the booming post-war economy, it was believed there was room for everyone again, and old racial wrongs were righted by removing national quotas and emphasizing family unification. Most post-war immigrants, unlike those of the great waves of the 19th and early 20th centuries, were the relatives of earlier immigrants. Little attention was paid to who these people were, what education and skills they had and, most significantly, what the needs of the American economy were in comparison. This is the system largely in place today.
But what if we can do better, a lot better, for the needs of the 21st century?
The monetary reasons are there, what Trump is aiming for. Immigrants and their children founded nearly half of the Fortune 500 companies. These include 5 of the top 12: NVidia, founded by a Taiwan national with a Master’s from Stanford; Apple; founded by the son of a Syrian, no degree; Google, cofounded by a Russian immigrant, also with an M.A. from Stanford; Amazon, founded by the son of a Cuban immigrant with a degree from Princeton; and Costco, founded by the son of Canadian immigrants (San Diego City College) whose family emigrated from Romania. These companies alone posted a combined revenue of $1.4 trillion in fiscal year 2023, more than the gross domestic product of many nations. And immigrants are about 80 percent more likely to start a company than U.S.-born citizens.
And that’s not to say someone else, in this instance the UK, hasn’t already tried the idea and screwed it up by being too generous. Britain has a scheme which allows most college grads to stay on for two years and work toward residency (as does in fact the U.S., it’s called “Optional Practical Training” with its own arcane set of regulations, available to almost all foreign students.)
The UK Graduate Route, which is a post-study visa, allows graduates to stay and work in the UK for up to two years after finalizing their studies. The government estimates that this visa has attracted many migrants to the UK, with them often misusing their benefits. More than 40 percent of people coming to the country for employment purposes in 2023 came from India or Nigeria. Talks for new rules follow plans to ban British universities from accepting certain postgraduates, in an effort to reduce net migration in the UK, which is highly driven by international students.
So there are lessons learned out there. Meanwhile, let’s not make the same mistake with college grads we made with relatives of earlier immigrants; this time let us separate the baby from the bathwater and get rid of the less valuable part. Instead of handing out green cards willy-nilly with each diploma, subject grads to a merit-based system, with points awarded to skills/majors in demand, accredited schools that rank well nationally, high GPAs, as well as English ability and proven entrepreneurial skills. Trump is close to right in singling out foreign-born college grads. We need only to tweak the system he proposes to pick out the very best America deserves.
Copyright © 2024. All rights reserved. The views expressed here are solely those of the author(s) in their private capacity.
Canada’s Changing Mission in Iraq
Think what it must be like to be one of America’s allies.
You enjoy some trade, groove on uber-Americanos like Beyonce and Brad Pitt, and visit Disneyland. But then there’s America again at your cubicle, asking again that you join some coalition, get some troops into another wacky American overseas intervention for freedom, or regime change, or to stop another impending genocide only American can stop. What can you do? It’s hard to say no, but given how poorly the last one worked out, and the one before that, and the one before that, nobody at home is in favor of another round. Still, you’re stuck giving something…And so it is with Canada, that big snowy place near the U.S. that is not Mexico (why doesn’t Mexico have to join these coalitions anyway?)
New Canadian Prime Minister Justin Trudeau fulfilled one of his most contentious election campaign promises, as Canadian military airstrikes on Islamic State in Iraq and Syria ceased in mid-February. Canada is still indirectly involved in the aerial campaign, and in training Iraqi security forces.“I’m very happy that the government has decided that there may be more productive things that they can focus on than bombing,” said one independent research and advocacy group based in Ottawa. “They’re indirectly continuing to participate in the air campaign, but at least they’re not directly participating and I think that’s an important step forward.”
Canada formally announced it had stopped all air strikes in Iraq and Syria on 15 February. They will continue to fly aerial refueling missions, and conduct reconnaissance from the air. More significantly, Canada will up its small ground forces, who are engaged in what has to be the longest and most thorough training mission in human history, inside Iraq.
As a side note, somebody from the West has been training Iraqi and Kurdish troops since around 2005. After 11 years, you’d think they would be the best-trained soldiers in the world (HINT: They are not.)
The motion presented to the House of Commons about changing the Iraq mission stipulates that Canada will work to engage with political leaders in the Middle East in the aim of “finding political solutions” in the region. No one in Canada has elaborated on how it plans to aid Iraq establish good governance. That process, too, has been ongoing since 2003, without much to show for it.
Oh Canada!
Copyright © 2024. All rights reserved. The views expressed here are solely those of the author(s) in their private capacity.
Merci, and Good Riddance – Canada Withdrawing Fighter Jets from Iraq, Syria
America’s presidential candidates go on TV and brag about killing a man with their own hands (one guy) and froth over the idea of starting even more wars (all the others.) In Canada, they get a supermodel as their new king, who speaks French, looks like a young Matthew McConaughey, and who tells America to shove its stupid wars up its overweight *ss.
Canada’s prime minister-elect, Justin Trudeau, pictured looking fabulous, said Tuesday he told Barack Obama that Canadian fighter jets would withdraw from fighting Islamic State in Iraq and Syria.
Western nations only go to war when coerced by the United States in joining some coalition. No other nation on the planet makes war as often and as unsuccessfully as the United States. No other nation makes war its business.
So you can imagine the huge hassle it is for Canada to have to suck up to its war-loving, gluten-free neighbor to the south, tossing in a few planes or troops whenever America has another hissy fit and has to invade somewhere. Canada famously refused to be sucked into the 2003 Iraq invasion, for example (though did play in Afghanistan.)
Quick question: what about Mexico? They also share a border and NAFTA with America, plus America graciously buys up 99 percent of its dope crop, and thus has the same need to suck up, but they also always seem to duck these war calls. Hmmm.
Anyway, Trudeau said “while Canada remains a strong member of the coalition against ISIL,” he made clear to Obama “the commitments I have made around ending the combat mission.”
It was not immediately clear if Trudeau added “you warmongering bastard” and/or said he’d nail Michelle with his old man’s “moves like Jagger” at the next state dinner.
Oh Canada!
Copyright © 2024. All rights reserved. The views expressed here are solely those of the author(s) in their private capacity.
Child, Imprisoned by U.S. in Guantánamo at Age 15, Granted Bail in Canada
History will remember us, but not well, and not as good and as just.
For we were the most powerful nation on earth, and we imprisoned a child named Omar Khadr in an off-shore penal colony, in the 21st century.
Omar Khadr in Canada
A Canadian court ordered on April 24 that Omar Khadr, the only Canadian to have been imprisoned at Guantánamo, be released on bail after 13 years in that shameful place. Khadr was thrown into Gitmo at age 15.
In 2010, eight years after his imprisonment commenced, Khadr pleaded guilty before a military commission to killing an American soldier with a grenade in 2002 during a battle in Afghanistan that also left Khadr severely wounded. Khadr is now 28, having spent the latter half of his childhood in an American prison.
Khadr was returned to Canada in 2012 to serve the remainder of the sentence the United States imposed, after he had already served eight years. He is now in a prison in Alberta. Another hearing at the Court of Queen’s Bench will determine when he will be released and will set conditions. The decision noted that the Canadian government challenged evidence that Khadr had been a model prisoner and that he was a “strong candidate” for release. Canada’s Conservative government had been reluctant to accept Khadr now that the U.S. is doing some housecleaning in Gitmo. Canada’s public safety minister said the government would appeal the bail decision. It is unclear whether or not that step will bar Khadr’s release.
Prisoner at GitmoThe Canadians knew about Khadr.
In fact, they interviewed him in Guantanamo in 2003, observed by his American jailers. Khadr was just 16 then, and cried during the session. The Canadians told the kid that “we know who [your father] is… he is a lost cause.” Khadr responded “He didn’t do anything” and the Canadian interrogators moved on to question him about his brother, his mother and the whereabouts of other family members. Khadr mentioned his education had ended with 8th grade, and said he was forced into fighting in Afghanistan, something that sounds about right from a 15-year-old. He claimed his earlier confessions to his American jailers were false, that he just told them what they wanted to hear, again about right for a 15-year-old being questioned at length by professional interrogators, but you never know with these people, right?
According to a report by his Canadian government interrogators, “In an effort to make him more amenable and willing to talk,” [Redacted] has placed Omar on the frequent flyer program: for the three weeks before [Redacted’s] visit, Omar has not been permitted more than three hours in any one location. At three hours intervals he is moved to another cell block, thus denying him uninterrupted sleep and a continued change of neighbors. He will soon be placed in isolation for up to three weeks and then he will be interviewed again.” The Canadian writer cheerfully commented “He did not yawn or indicate in any way that he was tired throughout the two-hour interview. It seems likely that the natural resilience of a well-fed and healthy seventeen-year old are keeping him going.”
The Canadians gave him some food from McDonald’s and his first mail since arriving at Gitmo.
An Eye for an Eye
An American soldier wounded by Khadr 13 years ago is clear on his beliefs. “I’m a Western-civilization Christian,” said now-retired Green Beret Layne Morris. “I’ve been raised with the knowledge that people can and do change and improve themselves. I think most of us are trying to do that. But some people aren’t, and Omar Khadr has chosen a path which dictates that, as a result of his religion, he’s got to go to war against our society. Until he changes from that attitude, I’m not sure why we should turn him loose to wreak havoc on our friends and families and neighbors again.”
The retired Green Beret also has his own thoughts about his wearing a uniform while Khadr did not. “We have a long history of going to war with people who have answered the call from their country. And then when it’s over we’re able to sit down with our former enemies, shake hands and say, ‘we tried our best to kill each other but our countries are at peace now.’ But Omar Khadr hasn’t earned that status. He didn’t put on the uniform of his country. He trashed his country.”
It all makes sense, at least to retired Green Beret Layne Morris. He was blinded in Khadr’s attack, so an eye for eye seems a fair way to describe his feelings 13 years later.
Whose War?
Now somewhere out there is a reader who is saying “But the little bastard killed an American soldier. He deserved to be punished.” Maybe so. Justice is a tricky thing. But no American soldier was punished in Afghanistan for killing on the battlefield, and two presidents of the most powerful nation on earth were never punished for using drones to kill children.
Copyright © 2024. All rights reserved. The views expressed here are solely those of the author(s) in their private capacity.
Radio Interview: CBC Dispatches
Available now as a podcast, or over the radio in Canada, is my interview with CBC Radio’s news magazine program, Dispatches.
The interview is described as “A failure in Iraq, from an American diplomat who ruefully admits helping lose the battle for the hearts and minds of the Iraqi people” and includes me reading from several chapters in the book. The questions were very good, very focused, and I think you will enjoy the interview.
Available online now at CBC Radio.
Copyright © 2024. All rights reserved. The views expressed here are solely those of the author(s) in their private capacity.
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