Dealing with the free - Missing the freedom

I had my vacation planned perfectly. Family day long weekend skiing in Quebec, hanging around with friends for another day in Montreal, a leisurely drive home, a day of doing nothing, then off to Lake Rousseau to meet the like-minded. Except on the third day of skiing I went stupid thinking that my mediocre skills will be suitable for the super icy double diamond run at the end of the day. After a flying flip I landed on my shoulder, heard the crack, felt the pain then tried to figure out how to stop myself from sliding down head first.

It took 50 meters.  I totaled my skis and broke my clavicle. This was the story in a nutshell; it wouldn’t even be worth mentioning except for what came after. Dealing with our amazing health care system was unavoidable and that is what I want to talk to you about.

My wife was behind me on the hill; she stopped to check me then continued down to get help. The ski patrol was with me within a few minutes. They knew what to do; they were quick, helpful, friendly and professional. They were volunteers. When I told them that I think I will faint, they immediately focused all of their efforts on keeping me from doing that. So I didn’t. By the time they put the sling on me in the first aid room my nausea was gone, I was completely with it. They offered to call us an ambulance, we decided to take our car to go to the closest hospital.

The triage nurse took my temperature and measured my blood pressure even though there was no indication that I needed either. I had a broken bone. Then she asked me if I can stand up and since I could, she directed me to the waiting room. The waiting room was eminently uncomfortable. None of the chairs had armrests, which is the thing I would have needed the most in my condition. My wife found me a wheelchair, and after an hour, she asked the admitting nurse how long the wait is likely to take. He didn’t know. Approximately? He didn’t know. Some time later my friend tried to inquire. He still did not know. After three hours of pain and discomfort I went to ask. He still did not know. Guess, I said. How many people are in front of us? There are people in this room, he said, who are here since 7am. This conversation took place at 9pm. I pressed again. He does not know how many ambulances will come through the door with more serious injuries than mine and he has 30 people on stretchers inside waiting for the single doctor on duty. Even if there is no new patient coming through the door, there is no way that I can possibly see a doctor before 7am next morning. He could have told this to us when we stepped in or at least the first time we asked. We decided to leave, drive to Montreal and take our chance there, a short drive from the place where we would be staying. We got to Royal Victoria around 10:30PM. Triage, temperature, blood pressure, wait. Four hours. Then we were taken to a doctor. A resident who ran to the doctor for approval for anything she did. After consulting with the doctor, she concluded that I needed an X-ray. I just had to go back to the waiting room and wait to be called. I asked her if it ever happened that a person claiming to have a broken bone was not X-rayed. She said no. So why didn’t they ask for one already I asked. Because only a doctor can order it and only after the doctor examined me.

After another half an hour wait, I was taken to radiology. The technician started manipulating me without any consideration for my pain. After the third take I told her that I am very dizzy and nauseated and I am afraid I am going to faint. After the fourth, while she was doing another painful repositioning I just kept repeating that I am going to faint, I am going to faint. Just hold it there she said, turned around and left while I fainted. I hit my head on the floor so hard that I got an ugly cut needing several stitches. I came about lying in my blood. The technician claimed that she did not hear me saying that I am about to faint.

Eventually, the resident doctor stitched me up. The hospital sold us a sling and sent us home saying that I have to come back for a follow up. But I live in Toronto. Then you have to go for a follow up there. Can I have at least the X-rays? Yes, if you are willing to wait. Eventually, we got out of the hospital at 7:30 am, me being in worse shape than I was when I got in. They did nothing to my arm except selling me a better looking sling than the makeshift one I went in with; but I also had five real ugly stitches on my head.

We were dead tired, so we spent another day in Montreal before heading back to Toronto. We went to the St Joseph fracture clinic with the X-rays we brought from Montreal. They cannot use those there we were told. The only way I can get to the fracture clinic is through the emergency department of the hospital. Triage, temperature, blood pressure, wait. Doctor, wait, X-ray, wait, doctor saying yup, it is broken. You don’t say, says I. Took us from 9am to 4:30pm. Fracture clinic the next morning with properly authorized local X-rays. The nature of my injury is such that not much can be done about it. It is supposed to heal on its own, I just have to rest and keep it from moving as much as possible. ALL I NEEDED from the health care system was a set of X-rays, a sling and somebody to tell me what I need to do and what I can expect. In a normally functioning system this should have taken 1-2 hours at a cost of maybe a few hundred dollars. If I was a dog, this is what it would have taken.

Sorry for the long story, but I had to tell it so that you can relate to my questions and general bewilderment over the state of the system. As you can imagine, I had plenty of time to think and to observe. The questions that preoccupied me the most were about waste and cost.

Why is the cost hidden?

Why can’t I get a bill when I get out of the hospital? Or later in the mail. Why can I not check how much I cost to the system on-line? Why can I not get a statement every year indicating how much I paid into the system and how much I took out? Why can’t we have it straight? Why can’t we have a system with true transparency? Who benefits from the costs being hidden?

How much did this all cost?

I don’t have a clue. Do you? What is the cost of a blood test? An X-ray? An MRI? The triage nurse taking my temperature and blood pressure? What was the total cost of my accident to the system? What was the cost of the unnecessary duplication? The cost of fixing their own screw-up? Why aren’t we asking these questions? Wouldn’t you like to know?

I have no idea whether the Cowansville hospital had the audacity of sending the bill to OHIP for making me wait 3 hours before telling me that I will not have a chance to see a doctor within another 12.

I also don’t know, but I am willing to bet, that Royal Victoria did charge for fixing the problem they caused (the stitches on my head). Could a private business afford to charge the client for fixing the harm they caused? If this was paid by my private insurance, I would most definitely instruct them not to pay, but what can I do if I don’t even have a way to know what the charges were? It is not my money. It belongs to the system. It is none of my business. Would you pay from your own pocket for an unnecessary procedure twice? This is why the health care providers like the system the way it is. Since you do not pay for it, you don’t have a say. They control the way the ‘social goods’ are distributed. They can repeat procedures unnecessarily; they can create work for themselves, they can be irresponsible, uncaring and sloppy and you cannot say a thing because for you, it is “free.” For them, it is work on their terms without the need to please you.

What about the value of my time?

Indeed………. Even if we forget about the discomfort and the suffering and consider only the time, can’t we try to put a figure to it? I value my time highly but nobody in the system seems to do. My time is worthless the moment I enter it.

The cost of a sling

My wife was called away at some point in Royal Victoria to pay for the sling. $18.- for a piece of cloth that couldn’t possibly cost more than a dollar to manufacture.( In Toronto we had to buy another one for $30.-). What was amazing is the effort they put into collecting the money. She had an escort all the way to make sure that she did pay the cost of what is not provided by the system. I could ask why not? What’s the difference between a cast and a sling? Why would one type of cast be free while I would have to pay for another? Isn’t that two tier medicine? A different health-care for those who can afford it? Doesn’t that go against the very principle of our health care system? What if I did not have the money? Would they have left me to die sling-less on the streets American style? The universality of the care is a sham. Why are we keeping up the pretense?

How many X-ray technicians does a patient need?

When I fell in the X-ray room, the technician needed help. The man who helped me up asked me what happened. I told him that she did not take me seriously when I said that I am going to faint. She said she did not hear me. He said “that’s why I keep saying that we need two technicians in the X-ray rooms.”
I held myself back from saying “no, we only need one who cares”
It wasn’t really clear what he meant. Do they need two persons to prevent such accidents or to prevent dispute over their causes? It does not really matter, because the important aspect was the union attitude behind the comment: spread the work and the responsibility. Two people are better in the system than one, especially since it makes no difference in the ‘profitability’ of the public enterprise. The true goal of any socialised service is to grow, never to become efficient. Such is the nature of socialized monopolies.

The ambulance workers

While waiting in Royal Victoria, several ambulance crews passed me by. Well, they didn’t actually pass; they just stopped and hung around. I would say an average two hours. It seems that the rule is that they cannot leave the patients until a doctor takes responsibility for them. Then they spend another hour doing paperwork. Seeing this, my respect for the profession diminished considerably. I always thought that they are the hard working good guys. Knowing that they are unionized should have given me a pause, but I guess I never really considered the implications. It was fascinating to see how they were doing nothing for hours. Goofing around. Chatting. Getting visibly bored.

It was also interesting to see who they were bringing in. The one standing next to me the longest was a seriously drunk girl who probably just fell off her high heels. I don’t actually know, and I should not make assumptions about the seriousness of other people’s suffering, but I couldn’t help thinking that some of these people getting ahead of me in the line (just to release the ambulance workers an hour or two sooner) did not have a condition more serious than mine.

The sad thing is that I learned my lesson. At the ski hill I was offered an ambulance. They could have called one if we wanted it. It seemed reasonable to us to go ourselves in our own car. If anything like this ever happens to me again, I will ask for the ambulance. I have no financial incentive not to and once I get to the hospital, I immediately jump a bit ahead in the queue while lying on a comfortable stretcher. The system is made to be abused as abusers have a clear advantage.

Our memories of communism

Both my wife and I grew up in a communist country (Hungary for me, Czechoslovakia for her). After spending more than half of our lives in Canada, we have the eerie feeling that communism is catching up with us. It is very difficult to translate these feelings and we feel quite frustrated by our apparent inability to convey our sense of déja vue and the meaning of the many signs and manifestations around us.

The essence of any socialised service is that you lose control over it. Not just over choice, not just over cost, but over the whole interaction with the system. As a customer, you are king because the money is coming from you. If the money is coming from somewhere else, so does the power. The system no longer exists to please you in return for your money, it exists to please its masters. If you are not an asset (a paying customer) then you are a liability (another drain on the system’s resources). If you are a paying customer, you are doing a favour by buying the service from them. If it is ‘free’ then they are doing a favour by dispensing it to you. It may seem like an insignificant detail, but it defines fundamentally the relationship between the parties of the transaction. When you get something for free you get what you paid for. For the “free” system we have, we gave up the most important freedom, our freedom to choose, to make decisions for ourselves.

All throughout my dealings with the system it made me feel unwanted. A burden. Extra cost. Extra work. More liability. A nuisance. It is no longer the case that they are there for me. I am there for them. My only excuse for being in the system is to justify their existence in the system. In three different hospitals, I never got a smile, a sign of compassion, a pleasant interaction. We were used to this. We grew up with it. We ran away from it but now it is catching up with us. We could discuss the economics, the bad incentives, the waste, but it is this human element that worries me the most.
Mark Steyn took issue with one of his readers who wrote to him “we are rich, we can afford to be stupid” pointing out that no, we cannot.
The biggest crime of socialism is that it destroys individual morality, that it creates bad behaviour.  Even if we could afford to be stupid, how much of our civility and good will can we afford to give up?

I did not have a dramatic experience. I did not die and when they broke the skin on my head they stitched it up.
Still, it was an all-out unpleasant experience. It also made me contemplate some hypothetical questions. If any of the thirty people with the more serious injuries waiting on the stretchers for the single doctor on duty in Cowansville would have died, how would that be reported? “Mr. John Doe suffered life threatening injuries in a car accident and succumbed to his injuries in the hospital”? Would anybody factor in the waiting time? The possible misjudgment of the triage nurse? At what point does a nuisance become a danger?
Everybody knows that the system is unsustainable and that it will get a lot worse. Reform attempts predictably fail.

Is there a solution?

I am a libertarian, so I, of course, know what the solution is. Whether Canadians would ever consider implementing it is another question. Saying that the government should have no more to do with health care than they do with baked goods, footwear or car insurance wouldn’t fly well with the general public. The majority of Canadians think that they have the best system in the world. The majority of Canadians have very little experience with the system so they do not really know what they are talking about, and nobody, not even people who oppose the socialized system have a real notion of its actual cost. Not in terms they can relate to.

Can anything be done?

I would like to think so, and I would like to know what you think. I will start with a few ideas.

The problem with the single payer systems is not that there is only a single payer, but the fact that the single payer decides who, what, when and how it will pay. If the system would pay for everything that it claims to cover, it would go broke within a year. Universal coverage is a lie. Rationed care is no care.
Waiting times of any kind are a form of rationing (they effectively rationed me out of Cowansville. The system refused to treat me under acceptable conditions) Demanding that the system pay for any medically justified service no matter who performs it and where is not a very libertarian approach, but it would expose the failings of the system faster than you could say “single payer health care system.”
(I do not like this idea, but it might get broad support)

There are voices asking for doing away with the single payer system by allowing private paying practices for those who can afford it and are willing to pay for it. It would be one way to erode the system, but I am not sure how much of a chance there is to get to it. What we can do is demanding transparency. In the age of computers there is no excuse not to provide it. I would like to know down to the penny, how much of my money is going into the health care system, but even more importantly, I would like to know how much the system is spending on me. I want to know the cost of every test, every procedure. The system we have is an open invitation for abuse, incompetence and fraud. Let’s expose it, let’s demand complete transparency. Once we can all see how rotten it is, we can start talking seriously about sensible ways to get rid of it.