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Americans Want Healthcare Choice



October 30, 2009 – Comments (18)

So let's figure out what we are getting, and try to identify what our Private Insurers contribute that is so expensive. Canada has Single Payer healthcare, wherein the Gov't pays the Doctors and all Canadians have access to equal quality of care. It is paid for by a tax which replaces insurance premiums. Their cost is half of ours. Let's see what choices they surrender in order to achieve their savings. We have an opportunity to provide for ourselves, as the Canadians provide for themselves. Representative Wiener has written an amendment to the House Bill which replaces it with the text of HR676, the only bill in Congress which will actually lower health insurance costs. Senator Bernie Sanders of Vt is introducing a similar bill into the Senate. There are no savings in the bill that Nancy Pelosi is bringing to the floor.

Please consider what "choices" you want for yourself.  For more information:

You can sign a petition in support of the Wiener Amendment here: 


Choice, as explained by Dr Allan Detsky:


Insurance Coverage

United States

All US citizens, other than those aged 65 years or older and the very poor, make the choice to purchase private health insurance (or not). It is estimated that nearly 47 million individuals have no coverage. It is unknown how many choose not to purchase coverage, cannot afford coverage, or cannot obtain coverage. Uninsured persons are severely limited in all other health care choices. They must either receive charity care or pay for care out of pocket, possibly incurring substantial debt or bankruptcy.

The choice of insurance plan is also often limited; 96% of US Metropolitan Statistical Areas have insurance markets that are highly concentrated, consolidated among only a few companies.2-3 Employers who offer health insurance also frequently limit choices. One plan is often established as preferred and made less expensive through lower premiums and co-payments. Few working adults can afford to purchase plans outside of their employer because other plans’ costs and risks are neither subsidized nor pooled. In addition, loss or change of jobs often results in loss of insurance coverage or substantially higher payments to retain existing coverage.

In contrast, insurers have the choice to accept or deny individuals coverage for innumerable reasons, often related to prior or current medical conditions. They may even deny coverage among those they insure for specific care related to preexisting conditions.


All Canadian citizens and landed immigrants are eligible to receive health insurance through the 1 government-sponsored plan administered by their province or territory. Because the application process is simple, without screening for current or preexisting health conditions or means testing, unenrolled individuals who seek care are routinely enrolled by clinical practices and hospitals, removing the need for charity care. Insurance coverage is not tied to employment and so does not change with loss or change of jobs.

The Canadian government mandates that all provincial plans cover “necessary care,” including most physician and hospital services. However, there are private insurance plans to obtain coverage for services that are not covered by some provincial plans, such as pharmaceuticals, private rooms in hospitals, dental care, home care, physiotherapy, and chiropractic care.

Hospitals and Physicians

United States

The choice of hospital or physician is often made by an individual’s insurance plan. Whether structured as a health maintenance organization, preferred provider organization, or otherwise, most plans attempt to limit costs by designating hospitals and physicians, offering either discounted coinsurance or additional benefits to promote their use. Receiving care “out of network” requires that individuals pay substantially larger co-payments.

Health insurance plans often require individuals to choose a primary care physician on enrollment who arranges referrals to specialist physicians. Forty percent of sicker adult Americans report difficulties seeing a specialist, 40% because of long waiting times, 31% because of a denied referral or waiting for a referral, and 17% because they cannot afford private insurance.4

Choice is also influenced by availability of care. The United States ranks last in international comparisons for patients finding it somewhat or very difficult to obtain care on nights or weekends without going to an emergency department.5


Canadians may choose to receive care from any physician or hospital anywhere in Canada. Typically, a family physician provides primary care and makes referrals to specialists. There is no limit to the number of different physicians a patient can see. If patients are not satisfied with the care of one physician or hospital, they may change to another. Specialists generally require a referral from another physician (not necessarily the family physician) to be reimbursed for a “consultation” but can evaluate any patient and be reimbursed for an “assessment.” Individuals may present to any hospital emergency department and request specialty care, which is scheduled as long as the emergency physician, who has no incentive not to, agrees.

Diagnostic Testing and Treatments

United States

The common presumption is that there is access to every new diagnostic test, procedure, medication, and intervention in the United States. However, insurance plans make use of formularies that restrict medications. Generally, at least 1 medication in any pharmacologic class is offered among “first-tier” medications, for which co-payments are the least expensive. Choosing less expensive or generic medications is also facilitated by requiring prior authorization for brand-name medications when a generic alternative exists or by offering 1 medication in a class at a lower co-payment after contracting with the manufacturer to obtain a discounted price.

Similarly, although many routine, less expensive services are not restricted, prior authorization is often used to limit the use of expensive health care services such as magnetic resonance imaging or experimental interventions.

In international comparisons, US waiting times are consistently shorter for elective surgeries and procedures.6 However, even though physicians and hospitals generally are able and willing to provide care quickly and efficiently, insurance plans are not necessarily similarly willing to fully reimburse charges. Often, it is not until after the procedure and utilization review that patients become aware of the substantial portion of the payment they must incur.


Virtually all health care services available in the United States are also available in Canada. There is regionalization of specialized services, such as surgical, oncology, or imaging procedures. For services unavailable in all parts of Canada, such as gamma knife surgery, governments will reimburse care received in the United States, but patients are required to apply in advance. In contrast with common perception, Canadians’ use of elective health care services in the United States is not common.7 For care in Canada, there is no utilization review and all services are covered in full without co-payment. Physicians and hospitals are paid promptly by the government. Patients receive no bill and fill out no forms. However, as opposed to prior authorization, the use of expensive health care services is limited by supply; there are fewer facilities per capita that provide this care. Provincial and private drug plans use formularies similar to those in the United States.

Waiting time is less a health care issue than a political one. Both federal and provincial governments have responded to media-facilitated public pressure to reduce wait times for specific services, such as hip and knee replacement, cataract surgery, cancer surgery, and emergency care through strategies that resemble pay for performance.8-9 Moreover, there is provincial variation in reliance on private facilities that charge individuals directly for common diagnostic services (eg, blood drawing, imaging); some provinces have allowed (or tacitly encouraged) these facilities, allowing patients to choose to pay for some routine care to receive it sooner.

The Bottom Line

Government-sponsored plans like Canada’s are frequently publicly portrayed as limiting choice. However, there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.



Corresponding Author: Allan S. Detsky, MD, PhD, Mount Sinai Hospital, 429-600 University Ave, Toronto, ON M5G 1X5, Canada (

Financial Disclosures: None reported.

Funding/Support: Dr Ross is currently supported by the National Institute on Aging (K08 AG032886) and by the American Federation of Aging Research through the Paul B. Beeson Career Development Award Program.

Role of the Sponsor: The funding organizations had no role in the preparation, review, or approval of the manuscript.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs.

Author Affiliations: Departments of Geriatrics and Palliative Care and Medicine, Mount Sinai School of Medicine, New York, New York, and Health Services Research and Development Research Enhancement Award Program and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Administration Medical Center, Bronx, New York (Dr Ross); Department of Medicine, Mount Sinai Hospital and University Health Network, and Departments of Health Policy, Management, and Evaluation and Medicine, University of Toronto, Toronto, Ontario, Canada (Dr Detsky

18 Comments – Post Your Own

#1) On October 30, 2009 at 8:25 AM, devoish (70.17) wrote:

JulieFremont, CAHeathcare Status: Employer Insured

My husband has been taking the same prescribed medications for the past few years. Now my employer had unilaterally changed our coverage, and the new insurance is refusing to pay for the same medicines unless they were pre-approved. My husband first sent in the prescriptions to mail order pharmacy recommended by our insurance company. The medicines did not come as expected, so he called and found out that the MD who ordered the medicine must "pre-authorized” the prescription. The MD office have since sent at least two "pre-authorization requests". It has been almost two months, we still have not gotten the medicines. The prescriptions are for controlling blood pressure, cholesterol and blood sugar. The MD had been supplying him the medicines to get through the gap. but it will not last. It will be a tremendous financial strain for us to continue paying for the prescriptions. Our insurance is still giving us the run around on the bureaucratic red tapes they created to delay/deny paying for the important medicines that could potentially prevent catastrophic medical emergencies.

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#2) On October 30, 2009 at 8:28 AM, devoish (70.17) wrote:

DeniseFrankfort, ILHeathcare Status: Employer Insured

I had a new breast abnormality with a normal mammogram and ultrasound. Because I had been diagnosed with breast cancer 4 years earlier (and supposedly cured), the oncologist recommended an MRI. My BlueCross PPO refused to cover it, saying it was not medically necessary. After fighting and fighting, I finally just charged the MRI to my Visa card and had the test. Lucky I did, because the MRI found another large breast cancer.

I had a mastectomy and chemo for 2 months. I appealed the insurance decision and lost the appeal, even after they learned that the MRI was diagnostic of the cancer. They did not care. I'm fortunate to be in the position to charge a life-saving test to my credit card. Others would not have been.

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#3) On October 30, 2009 at 8:30 AM, devoish (70.17) wrote:

Tell your story here. 

Read more stories here: 

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#4) On October 30, 2009 at 8:39 AM, danteps (28.75) wrote:

I am a Canadian and proud to admit that I recently traveled to the U.S. for a surgical procedure.  Unfortunately, in Canada we have rationing of care, long waiting times and subpar care relative to top-notch hospitals in the U.S.

Thank you to the Cleveland Clinic - we have have nothing that compares in Canada.  Thank you to the best trained physicians in the world for taking care of me.  I am fortunate enough to have sufficient resources to come to the U.S. to recieve better care.  I am not sure how much longer I shall live, but if the U.S. decides to go with a national health care program,  my guess is that you will quite quickly see the overall quality disipate.

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#5) On October 30, 2009 at 9:09 AM, ChrisGraley (28.61) wrote:

Don't give details to devoish, dantemps.

In his mind, it's still all chocolate fountains and rainbows.

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#6) On October 30, 2009 at 9:13 AM, 4everlost (28.87) wrote:


You listened to "Whip it Good" a lot when you were younger, didn't you?  You've posted so many times how the US needs a gov't run health insurance plan - and you maintain that Canada's plan is wonderful.  Then you cite a couple of cases in which US citizens  had a bad result with their insurance company.  Let's stop that silly game.  You know as well as I do that I could find examples of the Canadian plan failing to meet the needs of its citizens - so there is no point in that excercise. 

I know there are many flaws in the US model (though I'm well taken care of by my plan).  I also know that I don't want the Federal Gov't of the US getting involved!  Why wouldn't we implement low cost free market alternatives before we embark on an ultra-expensive public plan?  Bottom line - me and 70% of Americans oppose the expense and the involvement of the Gov't.  How can you act as if you know what's best?  


BTW - what did this mean?:

#10) On October 14, 2009 at 3:43 PM, devoish (99.67) wrote:

You get a rec from me as does Schumpeter. I cannot believe you selected Madoff as you example of #1 instead of the health insurers and/or investment bankers though.

If Toyota destroys GM that is the creative destruction everyone celebrates.

If BONY lends to 6th Avenue electronics and allows them to undercut prices until Best Buy is driven out of business, not so much. And when they are done, and BBY goes out, then prices go up at 6th ave to pay the debt.

Do you think Schumpeter meant financial innovation as we have seen in the last decade?

And most important, #4 the result. Did Schumpeter talk about what would happen if the Democratic Majorities failed to form a welfare state, and left the businessmen and politicians in charge?

#12) On October 15, 2009 at 12:47 PM, 4everlost (94.54) wrote:


Isn't there a contradiction in here?:

"...what would happen if the Democratic Majorities failed to form a welfare state, and left the businessmen and politicians in charge?"

If the Democratic Majorities end up forming a welfare state then the politicians and special interest businessmen will be in charge!  Even worse, bureaucrats that are appointed by the politicians make decisions about what you can and cannot do.  The Constitution does not give the federal gub'ment the authority needed to form a welfare state.

Report this comment #13) On October 15, 2009 at 4:12 PM, devoish (99.67) wrote:


Politicians and businessmen are not a majority of Americans.

Of course politicians aren't a majority of Americans.  But when you advocate "to form a welfare state" it leaves the politicians and businessmen in charge -in a welfare state the gov't decides who gets what.  The gov't is made up of polititcians who are tied to their buddies in the business world.  So even though they are not a majority they would be in charge.  Please explain.



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#7) On October 30, 2009 at 10:15 AM, Option1307 (30.61) wrote:

However, there are private insurance plans to obtain coverage for services that are not covered by some provincial plans, such as pharmaceuticals, private rooms in hospitals, dental care, home care, physiotherapy, and chiropractic care.

Moreover, there is provincial variation in reliance on private facilities that charge individuals directly for common diagnostic services (eg, blood drawing, imaging); some provinces have allowed (or tacitly encouraged) these facilities, allowing patients to choose to pay for some routine care to receive it sooner.

Wait, why do people need to buy their own private insurance if the national system in Canada is so good Devoish? Isn't this essentially just promoting a two tier system that you are arguing against?

Individuals may present to any hospital emergency department and request specialty care, which is scheduled as long as the emergency physician, who has no incentive not to, agrees.

You can present to any emergency department here in the states and been seen, no questions asked, regardless of pay/insurance/etc.

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#8) On October 30, 2009 at 5:16 PM, devoish (70.17) wrote:

From the bottome up.


There is no perfect world. Should Medicare for All be passed, there will then be a battle to try to reduce what is covered by Medicare, to make room for insurers again. The more procedures that are not covered, the more likely people will be to buy additional insurance. A second tier. Look at the list you copied. Canada has some dental, we have some some dental but it costs you in either Country. In Canada I get a hospital stay, fully covered. In America, maybe yes maybe no. In Canada they are not paying for you to have a private room though, if you want that you have to buy private insurance for your upgrade or pay out of pocket.

In America I can present to any emergency dept, be stabilized and sent away. Not treated. And if it is the wrong hospital my insurer might not pay. I can incur a huge credit card bill at 28% if I do not have the cash. In Canada I will not be bankrupted.

Thank you for pointing out a major benefit of Canadian coverage.


You do not have 70% of Americans with you. You do not have good coverage, you just think you do. Go look for some stories.  My link has a thousand, Bernie Sanders asked for stories and within a few weeks had 4000 stories and 40,000 signatures on a petition for Medicare for All.


Most Americans cannot go to the Cleveland Clinic. It is "out of network". Did Canada pay for your treatment? I know Canadian healthcare will pay for any covered procedure even if you have to go so far out of network it is out of Country too. In the USA you have to be fortunate enough to have sufficient resources too. We just pay more to insurers before we need our own resources than you pay in taxes for Canadian healthcare before you need yours. And it turns out we need our own resources far more often.

I am sorry you may not recover from your illness and that whatever you have is not more easily treated.


It is all sprinkles and marshmallow frosting to me. Except when a thief gets dishonorable and I pre-pay top dollar for something and don't get it. Like health insurance. Then I don't mind putting that thief out of business.


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#9) On October 30, 2009 at 5:40 PM, starbucks4ever (87.71) wrote:

I don't need to sign a petition: the market is doing it for me today. And unlike any petitions written on paper, this one is in a language they understand.

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#10) On October 30, 2009 at 7:44 PM, devoish (70.17) wrote:

The stock market is the least qualified judge of legislation.

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#11) On October 30, 2009 at 10:18 PM, ChrisGraley (28.61) wrote:

How diluted can you be devoish?

Dantemps just told you that if he didn't go to Cleveland Clinic that he would have probably died. 

He didn't pay charges for being "Out of network" he paid the charges for being uninsured which is much worse according to you, unless you've lied in previous posts.

I would really like for you and Michael Moore to get on a boat together and go to Cuba where they have the same opinion on health care as you do. That way everyone in the world would be happy! You wouldn't have to force the health care that you want on the rest of the world, and the rest of the world wouldn't have to read  your stupid posts because they wouldn't let you have an internet connection in Cuba.

You have to agree that a win/win is always the best solution.

After all, you have always been in favor of the public option,and that is the only option that Cuba has.

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#12) On November 08, 2009 at 3:42 PM, FSaucy (99.24) wrote:

Chris, ad hominem is not valid argumentation, nor is drawing a comparison to the Cuban health system.  And you don't need to read his posts if you think they are stupid.

5 case studies is not compelling, but hundreds of thousands are.  And the rate is going up.  The fact is people get put to difficult decisions about their health more and more every day because the best insurance they can afford is a high deductible insurance that turns out inadequate when actually needed for an important procedure.  Yes, the insured are becoming sicker in the US as a result of the problems with the health insurance industry.  The uninsured or people with pre-existing conditions is only part of the problem.  Folks with insurance still need to decide things like "should I have the lumpectomy or should I make sure I can pay rent?"  I saw this exact case Thursday along with 2 other similar ones Friday.  These are nonelective, MD referred procedures that are being turned down by the patients because of money.  "I'll deal with the risks of not having the procedure, rather than the guarantee I'll be kicked out on the streets for not paying rent."  Almost the exact quote.

Anyone with the slightest industry experience realizes that patients need to make these kinds of decisions all the time now, it is increasing at a rapid rate, and that looking back even 10 years ago this was much less of a problem.  The current projection we are on is not good.

Those of you who currently support status quo will be ashamed 20 years down the line when we have a more civilized system and a healthier country because of the insight and courage to act that we are seeing by our current leadership.  Doing something is better than nothing, because doing something can't possibly make it worse.  Most people against health reform do not work in healthcare, and those who do support it.  I trust those who are actually knowledgeable on the subject.

This is just one of many surveys indicating how this divides out

I don't think that having good health is a right, in fact having bad health is eventually a certainty for everyone.  But it seems that any civilized society, especially the most prosperous one in the world, should care for their ill.

Here is a link with more studies from the peer review literature.  Personally I trust researchers who dedicate their lives to advancing human knowledge more than Fox News.  But that's just me.

There are links to four detailed studies on this page that specifically address the FACT that the Canadian system currently is making people healthier for cheaper.  It's not about Cuba, and it's not about socialism.  It's about being practical and being smart.

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#13) On November 08, 2009 at 4:11 PM, wolfman225 (45.17) wrote:

1st off:  Bernie Sanders is an idiot.  He's an unmitigated ass who transplanted himself into our once-great state from NYC in the sixties, got himself elected into public office, and has never earned an honest day's pay in his life!  Since he has never had to earn a paycheck, he is emminently unqualified to pontificate on what others should/should not be allowed to earn (or retain of their earnings).

2nd:  The very fact of the multitudes who come to the US for healthcare they are denied in their more "advanced"  and "compassionate" home countries, as well as the great number of proceedures done by US physicians (for free) in other countries puts the lie to your (and others') claims of the "inferior" and "unfair" US Healthcare System.

And finally:  as I posted in response to another blog on the healthcare debacle, I hope all of you remember these days when the tax rates have risen beyond 35% (70+% for the top 1%) and access to healthcare has been limited due to government mandates in the name of "cost control", while costs of care continue to increase for the general public even as the political class costs' remain low due to their oh-so-thoughtfully opting themselves out of the program they mandate for the rest of us in order to keep their own "gold plated health plan".

The main problem with democracy is that when Liberals get the government they vote for, so do the rest of us.

P.S.  In your title,  you state that Americans want "Choice".  True enough.  However, where is the choice in this bill?  It very clearly states that ALL options/insurance plans MUST conform to a formula approved by..........wait for it..........Obama's HHS Secretary! Hmmmmm.......sounds to me like the goverment has set itself up as the singular arbiter of what we will/will not be allowed to have for coverage, as well as what we will be forced to pay for it.  Some choice.

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#14) On November 08, 2009 at 4:33 PM, NOTvuffett (< 20) wrote:

How could creating a giant new beaurocracy to run health care not save us money? lol.  What could possibly go wrong?  By the government's own estimate there is 50-60 billion dollars of fraud in the Medicare program now.

If insurance companies are making so much money, why aren't we all investing in them?

And now for something completely different: early Devo, "Smart Patrol/Mr. DNA"

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#15) On November 08, 2009 at 4:36 PM, truthisntstupid (76.10) wrote:

Hey blockhead  There's a hell of a lot of people that have NO choice RIGHT NOW. 

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#16) On November 08, 2009 at 4:49 PM, wolfman225 (45.17) wrote:


"Blockhead"?  I'm sorry, Lucy, but I'm NOT going to let you hold the football for me.  The government won't cover the resulting injuries (bruised back, head trauma, bruised ego/damaged self-esteem.........).  I'm sure you understand.

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#17) On November 08, 2009 at 5:21 PM, truthisntstupid (76.10) wrote:

I wonder how many of you folks that have healthcare and feel so secure about it have it through an employer health plan.  Does the employer shoulder part or all of the cost? That should be taxed as income.  I hope it is.  You get something given to you that many people can't buy and most people can't afford it if they don't have employer-sponsored coverage.  As for your whining about taxes, be happy you make enough money to bitch about it.  Your taxes on the first $20,000 of income are no more than the taxes a person making $20,000 a year has to pay.  You all whine like you're paying higher taxes on EVERY PENNY of your income.  The rest of us know how tax brackets work, too.  A person making less money has to live on a lot less and would be glad for an opportunity to make more and not whine about the taxes.  He knows he would still be better off than he is at his present income level. 

People are watching their loved ones have to fight to get their insurance meet its obligations that thought they had coverage, too. And the insurance companies don't make as much money as everyone thinks they do because all the big shots in the insurance industry get paid so much.  Sure, the head of United Health got $120M.  How many underneath him got tens of millions, and how many under them got millions?  Did healthcare bankrupt the car companies?  Our companies can't compete in the global economy.  They have to compete with other companies in other countries and other companies in other countries don't have healthcare expense.  You don't think you can or should have to afford healthcare for everyone?  WE CAN'T AFFORD YOU.

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#18) On November 08, 2009 at 5:34 PM, wolfman225 (45.17) wrote:

@17--"You don't think you can or should have to afford healthcare for everyone? "

Precisely.  Got it in one!  Especially if, by "everyone", you mean illegal aliens (no provision for cert. of citizenship in the bill)  and people who refuse to take charge of their own health and continue to a) over eat, b) abuse drugs/alcohol, c) engage in inherently risky "alternative lifestyle" practices.......etc.

In an earlier speech on healthcare, Mr. Obama made a statement to the effect that people were going to have to be held accountable for their choices and that no one was/should be forced to pay for the poor choices of another.  Funny how that seems to have been left out of the Pelosi bill, ain't it?

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