The Cost of (Getting Sick Under) Socialized Medicine

I wanted to start this line of posts with the observation that there is no more nationally-specific experience than getting sick. But that’s not necessarily true. In Canada, provinces manage their own healthcare, and when I show you some pictures of where I stayed, you will understand why Michael Moore picked a nice Ontario clinic for his visit in Sicko. My illness has been a Quebec experience as much as it has been a Canadian experience.

When American friends would ask us about the Canadian system, we always said it had its quirks but that we liked it just fine. Carrie and I were both concerned about what would happen if someone got really sick and needed to be hospitalized. Fear of the unknown and all that. Also, some of the hospitals are just plain ugly. Still, when the diagnosis came down that I had thyroid cancer, I was shocked by how many Americans asked me if I’d be coming back across the border to get my healthcare. The idea seemed preposterous to me. I’m not insured to use the US system and we are talking about tens of thousands of dollars in healthcare, healthcare that I could get here for a fraction of that cost. In fact, when I joined the US thyroid cancer survivors listerv last fall, one of the things I found most emotionally overwhelming was the way in which healthcare costs and insurance figured into people’s narratives about their own experience and how their illness was managed.

I really have no Canada-specific complaints about my care, but I will leave complaints for another post. Instead, I thought I would start with the money end. We have socialized medicine here, supplemented by a private medical system. I really didn’t understand it when I first got here, and I still don’t understand a lot of it, but in addition to the provincial system, I pay for private insurance that covers some of my healthcare costs. That also means I can go to some private clinics and have tests done without paying the full cost. Though I gather that it is possible to be seen in a private clinic whether or not you have private insurance. I do know from watching my doctors that most of them have more than one office and are in different places on different days. But I won’t say more about that yet as I don’t fully grasp it yet.

Acute Costs of Cancer Treatment

So, to puncture the myth, we do not live in a socialist utopia up here. It is not actually free to get sick in Quebec, or anywhere else in Canada, though we like to think of it that way. To begin with, I have been drawing my salary while on short term disability (the unfortunately acronymed “STD,” as it is called). Up to six months at full pay, and you need a note from your doctor every month. After that, there’s long-term disability. That’s an amazing benefit of working at McGill. If I had some other kind of job, there might be real issues around lost income. Socialized medicine or no, that can mean that people can’t afford to get sick. Many people on my thyroid cancer listserv are not so fortunate. True, I lost some income on talks I wasn’t going to be able to give, but that’s just walking around money, not basic household income.

Second, there is the cost of the drugs. My drugs are relatively cheap for the most part, but the way it works in Quebec is that provincial healthcare will cover a portion of approved prescription healthcare costs if you don’t have supplemental private insurance, which almost every person with a professional-managerial job has. So i have an insurance company to whom I submit receipts, just like in the US. That said, everyone I have ever spoken to on both sides of the border says that drugs are cheaper here. I have done no research to confirm or refute that, but since I pay very little to begin with, I am not complaining.

Third, in addition to Quebec’s public system, there is a supplemental private system that caters to privileged people like me. If you are in a hurry and have good private insurance coverage (or a lot of disposable income), you can jump the queue on certain tests by going to a private clinic and paying for them. I did that for my biopsy ($200), and an early CT scan last fall (closer to $900). My insurance covered about 75% of those costs. If I hadn’t done that, I probably would have set my treatment back 2-3 months, which in my case, because thyroid cancer is a slow-growing cancer, probably wouldn’t have made a big health difference in the end, though it certainly would have messed up my sabbatical. Now, things move very quickly and I am getting all my tests for free in hospitals.

To review: so far, my total cost out of pocket for treatment for aggressive and nasty thyroid cancer is $250.

Now that I am a bona-fide cancer patient, I get all my tests and procedures for free in that I do not directly pay for them, and things have happened quite fast. Except there’s hospitalization.

Technically, hospitalization is also free, but if you go that route, they put you in a ward with 3 other people. In may case, after wandering around between recovery and ICU for a few days, I finally landed in a private room at Montreal General, which is what I wanted. I also spent a couple nights in a private room at the Jewish General in the fall after my first surgery. The private room for radioactive iodine was medically necessary and therefore not charged to me. Once again, insurance enters the picture. They cover a semi-private room (that’s with one other person). Since I selected a room with no roommates, I was charged half the cost, which is about $70 a day. That’s still a pile of money: my 17 days at Montreal General will cost just under $1100 when they get around to billing me for the part insurance didn’t cover, though our car repairs last week were close to that as well. And even if I had no private insurance, the total cost would only be about twice that at just under $2200 for 17 days’ hospitalization in a private room. And I could have had it free if I was willing to put up with roommates.

So, the total cost of my thyroid cancer thus far appears to be: about $1450 (plus lost talk income, which I’m not counting). Oh yes, I also bought 4 extra large hospital gowns through mail order, as the Jewish General gowns didn’t fit well. Montreal General had nice big gowns but they sort of hung over my trach, which wasn’t comfortable, so I was glad to have the gowns I bought. Total cost: $42 plus shipping.

But wait, there’s more. Let’s say you’re married to someone who looks after you in a devoted and exhausting fashion. Let’s say your mom comes and visits you and stays with you. Those costs are also part of getting sick. Here, things get a little fuzzier. I did not ask my mom the cost of her tickets but I’m sure they were hundreds of dollars, especially after having to switch her flight when my second surgery was delayed for a month while we explored our options. Public transit to Montreal General isn’t great and my mom’s mobility is such that we usually just drive her everywhere, so there were the options of parking for close to $20 a day — if you could find a spot — or taking a cab, which was over $20 each way (but no parking hassle). When Carrie was alone, or going by school, she did a combination of metro, walking and cabbing. Still, that’s another pile of cash. Some of this is mitigated by the fact that our leisure expenditures dropped to zero: no nights out for nice dinners and movies, no shows, no dinner parties, etc. But again, if you don’t live like us, this could add up to a lot of money quickly. On the other hand, you would probably have just taken the hit on time and found the bus that goes to and from MGH and combined that with the metro.

So I don’t know how to factor in those costs. They would have existed in the US as well, so I’m not sure that the comparison even matters, but clearly our privilege played a role in my experience of my illness and Carrie’s as well. We’re also lucky that my long hospital stay coincided with “study break” (=McGillspeak for “spring break” except it’s in February so spring is a distant fantasy), as there is no “care for your family leave” at McGill.

Therefore, I’ll say the really significant figure so far is $1500 and all of it was optional and the only impact on my end outcome was morale and convenience. These are not negligible at all, and totally worth $1500 to me. Of course, there may be hidden costs to external beam radiation. We shall see. In any event, on top of my “optional” services listed above, I got the following:

3 surgeries
second opinions
supervision by a team of doctors
daily visits from doctors while in the hospital
22 total days in the hospital
so many x-rays, blood tests and scans that I can’t count (including both a PET scan and a whole body scan)
radioactive iodine
thyrogen
a whole array of medications for pain, hormone levels and calcium
weekly speech therapy
access to the Hope & Cope centre (including a personal trainer)
and a surgeon and “team leader” who actually returns my emails
–I am sure I am forgetting some things

So there are some financials for you. Judge for yourself whether this system is superior to that of the United States or not.

Healthcare Costs as a Portion of Middle Class Income: One Case Study

The assumption is that Canadians pay for socialized medicine in higher taxes, which is probably true in some absolute sense but is also a meaningless statement. I can’t speak for others since I haven’t the economic data, but let’s use me as an example of someone who has lived under both the US and the Quebec systems. Every year I have enough withholding to warrant an income tax return after I contribute to my RRSP (=”IRA” for Americans), but leaving that aside, after taxes and fees were removed from my last paycheck, I took home just under 56% of my gross pay.(1) When I worked at the University of Pittsburgh, my fees for healthcare were much higher, I was paying local, state and federal income taxes and various fees, I took home just under 57% of my gross.(2)

These figures are meaningful because they are an aggregate of the costs of buying health insurance and income tax withholding (mixed in with some other benefits such as retirement, life insurance, old age security, and a few others which are themselves much smaller fractions of the amount withheld from my regular paycheck).

In other words, on a month to month basis, I am paying a roughly equivalent amount of money out of pocket for healthcare here, except that it is considered a right and not a privilege. Now it’s true that some Quebec emergency rooms are overcrowded (news flash: so are some American emergency rooms), that the hospital infrastructure is decaying and some people have to wait for some services an inordinately long time. The system is not perfect and could certainly improve in many ways. At the same time, it would be wrong to say that we are paying more for less, as although privileged people like me may pay a little more, nobody in Quebec will be dropped from insurance for being sick or go broke because of healthcare costs. And I pay less for prescription drugs, have no copays (for now), and can get in to see all sorts of specialists much faster than I could under the UPMC system, which was considered to be “excellent” healthcare in the US and was a point that the University of Pittsburgh used in their recruitment of new faculty.

Notes;

1. McGill employees know that that 57% is not actually a fair number, since certain provincial fees and taxes are paid off over the course of the year, and for the last few months of the year, you take home a higher percentage of your gross–in December, I has bringing home over 60% of my gross.

2. Again this isn’t the whole story. In the US I could deduct mortgage interest, but had to pay water, sewer, garbage collection so on. Here, we’ve got much higher sales taxes and can’t deduct mortgage interest (but the RRSP deduction makes a bigger impact on your return). So I probably do pay more taxes when you add it all up, but not by as much as you’d think given all the complaining people do around here.