We need more Canadians!

[Jean in Newcastle]

I'm not quite sure how to put this. I'm hearing a lot of American "of course we like to charitably help the needy" ideas. I want to focus on the subtle difference in Canadian perspective on that. We don't view people with health needs as "needy" to be responded to "charitably" -- my thinking follows an entirely different loop. You might think of it as something like entitlement, I guess. I think of it as a basic service of a civilized society. Like police.

 

I can't wrap my head around societies where some people would have police (and pay for them) and others would have no police service whatsoever. Does the analogy make sense? Do Americans think of policing as "a given"? I never think about how much it costs to have "universal" police coverage, or whether I "get my share" or whether people who "need more" should be entitled to it, in spite of the cost.

 

It's that kind of thinking that characterizes my attitude towards healthcare. I don't think of it in a "charitable" way. I don't say, "Yes, we should all kindly and willingly look after the needy." -- That would be like saying. "Gee, I'm so sad your child was kidnapped because you didn't have any police coverage. What a tragedy. You're raising money to hire a criminal task force? That must be expensive! What can I do to help?" (Instead of saying, "Aren't you entitled to a reasonable level of public safety? Don't you have people who just investigate crimes because they are crimes?")

 

Is my analogy holding? I hope I'm making sense.

But the truly needy are covered by the government and have been for many years.  So it is a given at least if you are talking about retaining the status quo either of what we have with ACA or even what we had before the ACA.  Most people (though there are some) are not talking about taking this access to healthcare away from them.

 

Part of the problem is that the people who have been covered for years are notorious in some cases for wasting money - the whole "going to the ER for a cold" scenario when there are other options available to them.  And the government programs themselves are notorious for wasting money.  Now there are measures to stop this and I think to some degree they are working.  There has been a concerted effort to get people to understand what the ER is for.  My impression is that that is working but I don't have the time to look for actual studies to see if this is correct.  And the government is trying to crack down and plug money leaks of their own.  But I'm not sure how successful that is and that is a huge reason why people don't trust them to manage the healthcare of even more people.  

 

Most of the people who fall through the cracks are people with a higher income - sometimes this is because they themselves have not signed up for help that was available for them.  Sometimes it is because their income is just over the cut off.  

[Jane in NC]

I'm not quite sure how to put this. I'm hearing a lot of American "of course we like to charitably help the needy" ideas. I want to focus on the subtle difference in Canadian perspective on that. We don't view people with health needs as "needy" to be responded to "charitably" -- my thinking follows an entirely different loop. You might think of it as something like entitlement, I guess. I think of it as a basic service of a civilized society. Like police.

 

I can't wrap my head around societies where some people would have police (and pay for them) and others would have no police service whatsoever. Does the analogy make sense? Do Americans think of policing as "a given"? I never think about how much it costs to have "universal" police coverage, or whether I "get my share" or whether people who "need more" should be entitled to it, in spite of the cost.

 

It's that kind of thinking that characterizes my attitude towards healthcare. I don't think of it in a "charitable" way. I don't say, "Yes, we should all kindly and willingly look after the needy." -- That would be like saying. "Gee, I'm so sad your child was kidnapped because you didn't have any police coverage. What a tragedy. You're raising money to hire a criminal task force? That must be expensive! What can I do to help?" (Instead of saying, "Aren't you entitled to a reasonable level of public safety? Don't you have people who just investigate crimes because they are crimes?")

 

Is my analogy holding? I hope I'm making sense.

 

A couple of years ago I was at a dinner party where a firefighter, a public employee, was in attendance. He was of the mindset that fire coverage should return to private enterprise, i.e. let the building burn (and people die!) if they were not subscribers to a service!  Yes, he was Libertarian to an extreme but I was stunned by the concept.

 

But the truly needy are covered by the government and have been for many years.  So it is a given at least if you are talking about retaining the status quo either of what we have with ACA or even what we had before the ACA.  Most people (though there are some) are not talking about taking this access to healthcare away from them.

 

Part of the problem is that the people who have been covered for years are notorious in some cases for wasting money - the whole "going to the ER for a cold" scenario when there are other options available to them.  And the government programs themselves are notorious for wasting money.  Now there are measures to stop this and I think to some degree they are working.  There has been a concerted effort to get people to understand what the ER is for.  My impression is that that is working but I don't have the time to look for actual studies to see if this is correct.  And the government is trying to crack down and plug money leaks of their own.  But I'm not sure how successful that is and that is a huge reason why people don't trust them to manage the healthcare of even more people.  

 

Most of the people who fall through the cracks are people with a higher income - sometimes this is because they themselves have not signed up for help that was available for them.  Sometimes it is because their income is just over the cut off.  

Maybe in your community. I live in a rural area where until five years ago there were no "doc in the boxes".  I am not even sure if those walk in places are open on weekends except during the peak tourist season of summer.  The health department walk in clinic is in a central location in my county but most people live at least ten or fifteen miles away.  One of the 4-H families with whom I work does not have a car. I am sure they are not along in being among the "truly needy" that lack transportation.

 

One of our wonderful dental practices just held a free procedure day. People started lining up pre-dawn.  When I was a poor grad student I had two dental options:  the dental school on campus or a low income clinic run by the health department.  There are no options in my rural community other than dentists in private practice who give discounts or those who offer procedures for free on occasion.

[Jean in Newcastle]

 

Maybe in your community. I live in a rural area where until five years ago there were no "doc in the boxes".  I am not even sure if those walk in places are open on weekends except during the peak tourist season of summer.  The health department walk in clinic is in a central location in my county but most people live at least ten or fifteen miles away.  One of the 4-H families with whom I work does not have a car. I am sure they are not along in being among the "truly needy" that lack transportation.

 

One of our wonderful dental practices just held a free procedure day. People started lining up pre-dawn.  When I was a poor grad student I had two dental options:  the dental school on campus or a low income clinic run by the health department.  There are no options in my rural community other than dentists in private practice who give discounts or those who offer procedures for free on occasion.

Yes, I live in an urban environment.  But the issue you're pointing out in your first example is one of transportation.  I don't think that universal medical coverage would fix that problem, would it?  And I think the problem of rural medical coverage would remain as well.  I think there are already some incentives available to get doctors to go out to rural areas but it isn't going to be the first choice of many doctors.  These are big problems, I agree.  

[Jane in NC]

Yes, I live in an urban environment.  But the issue you're pointing out in your first example is one of transportation.  I don't think that universal medical coverage would fix that problem, would it?  And I think the problem of rural medical coverage would remain as well.  I think there are already some incentives available to get doctors to go out to rural areas but it isn't going to be the first choice of many doctors.  These are big problems, I agree.  

 

You had mentioned poor people using the ER for non-emergency issues.  I noted that my community has not had private walk in clinics (what I call "doc in the boxes") until recently. A poor person without insurance would choose the ER over a private facility.  A poor person with insurance can perhaps now see the pediatrician in my community or choose the walk in clinic.  My community does not lack doctors. It is just that these doctors are in private practice or are employed by the community hospital.  (The free health department clinic is farther away.)

 

So while transportation is an issue, lack of insurance has been the larger one. 

[Frances]

I'm not quite sure how to put this. I'm hearing a lot of American "of course we like to charitably help the needy" ideas. I want to focus on the subtle difference in Canadian perspective on that. We don't view people with health needs as "needy" to be responded to "charitably" -- my thinking follows an entirely different loop. You might think of it as something like entitlement, I guess. I think of it as a basic service of a civilized society. Like police.

 

I can't wrap my head around societies where some people would have police (and pay for them) and others would have no police service whatsoever. Does the analogy make sense? Do Americans think of policing as "a given"? I never think about how much it costs to have "universal" police coverage, or whether I "get my share" or whether people who "need more" should be entitled to it, in spite of the cost.

 

It's that kind of thinking that characterizes my attitude towards healthcare. I don't think of it in a "charitable" way. I don't say, "Yes, we should all kindly and willingly look after the needy." -- That would be like saying. "Gee, I'm so sad your child was kidnapped because you didn't have any police coverage. What a tragedy. You're raising money to hire a criminal task force? That must be expensive! What can I do to help?" (Instead of saying, "Aren't you entitled to a reasonable level of public safety? Don't you have people who just investigate crimes because they are crimes?")

 

Is my analogy holding? I hope I'm making sense.

 

Sadly, the lack of policing is actually becoming a reality in some of the rural counties in our state. For many years, some counties and towns in them have relied heavily on compensatory payments from the federal government to fund their services after logging was restricted due to environmental concerns. Consequently, the areas had extremely low property tax rates relative to the rest of the state. Now that less federal money is being sent and often only provided at the last minute, many have had to make drastic cuts to law enforcement. For example, two sheriff deputies to patrol an area the size of Rhode Island and they only work 8-5 M-F. Repeated efforts to raise property taxes have failed and people have taken to arming themselves and forming citizen patrol groups. Gun sales and crime rates have increased significantly. When articles appear in the online versions of local newspapers about the situation, many of the comments are about limiting government, not trusting government, taking care of our own, etc.

 

http://www.nytimes.com/2013/07/06/us/In-Cash-Starved-Oregon-County-Citizens-Take-Up-Patrols.html?_r=0

[NASDAQ]

Maybe not all Americans would consider it inadequate  :001_smile: . My husband works in the healthcare system and his approach and advice to family and friends when they ask for his opinion is very much like one of the Canadians described in an earlier post as your Grandma's method. Even though we have excellent health insurance, we definitely take the wait and see if it will get better on its own approach and think a lot before starting down any path of medical intervention. Because from my husband's perspective based on years of experience, one thing leads to another and then another and then another, etc.

 

My husband is daily saddened to see the extreme and painful measures taken to keep people alive for just a few more hours or days. It is heartbreaking for him and he is so thankful that both of our dads had wonderful hospice experiences during their last days.

 

Except I wasn't talking about extreme measures for end-of-life care for the elderly. Those kinds of "easy" savings have already been made. I'm talking about waiting 2+ years to get your kid's scoliosis fixed. We have the longest wait times in the OECD.

[Audrey]

But the truly needy are covered by the government and have been for many years.  

 

 

The above shows that you entirely missed bolt's point -- that here, we do not think of anyone as "needy" when it comes to healthcare.  Everyone should have it.  "Needy," in the loaded context which you are using it, is not a term associated with healthcare here.  Hence, her analogy to police services.

[liber]

The thing with Canadian healthcare, IMO, is that it is reduced to the lowest common denominator. Sure we all get "free" healthcare, but low quality so that everyone can have it and some provinces are worse than others. I think it is a dying sacred cow that needs to be put out of its misery and come up with something better. What I don't know.

 

As to the documentary that started this thread, I'm sure it was heavily slanted as most docs are. I'm sure the makers didn't go out of their way to interview people who were upset with the system or who were even failed by the system.

[kbutton]

You had mentioned poor people using the ER for non-emergency issues.  I noted that my community has not had private walk in clinics (what I call "doc in the boxes") until recently. A poor person without insurance would choose the ER over a private facility.  A poor person with insurance can perhaps now see the pediatrician in my community or choose the walk in clinic.  My community does not lack doctors. It is just that these doctors are in private practice or are employed by the community hospital.  (The free health department clinic is farther away.)

 

So while transportation is an issue, lack of insurance has been the larger one. 

There are people in this situation; I do not argue with that, and the ER is an important piece of care for these folks. It makes me really sad to hear about the state of rural healthcare in some areas. I'm not at all suggesting with what I say in this post that the ER should go away as an option for folks. It does complicate things, and that is why many ERs have developed ways to work with this situation.

 

Unfortunately, in many, if not most, communities, this is a rosy view of what people use the ER for. Many people do, in fact, have access to several of these options (or to primary care docs), and they go to the ER for mosquito bites. Uncomplicated ones. In the middle of the night. They've had patients come in on an ambulance because they have a crush on a med tech, not because they are ill. It is possible to get yourself banned from ambulance service, but it's a hassle to jump through the hoops to reduce abuse. Not all of these types of patients are mentally ill in case you are wondering.

 

My husband does massive amounts of patient education, connects people to social workers, etc. That is the only thing that is going to help people learn to use medical care appropriately (and some people really are responsive to education). Many healthcare workers WILL NOT do this--I don't really know why because education ups patient compliance, goodwill, etc. That doesn't make anything work better, and I can't figure out why docs won't work harder on this front. In some cases, patients will tell my husband that he is the first person in X number of visits about such and such a condition to tell them what they actually needed to know to take care of themselves. That is a sorry state of affairs, and it's entirely fixable. In some cases, if the first doc had done so, my husband would not be seeing them at his place of work.

 

Longer waits will disproportionately hurt those who need serious help. The ACA is actually making it harder to help some people by basically cutting off compensation to hospitals, ERs, etc. if someone with a chronic condition that needs chronic management comes in "too often" as defined by the ACA and it's flowchart, not as defined by the actual medical status of the patient. Studies of ER recidivism point to several key factors for reducing frequent flyers in the ER, but I am pretty sure the ACA addresses only those frequent flyers that actually need to be there, and it penalizes them. This is not a step in the right direction. It really upsets me that we don't educate people about bug bites, but we'll shut off care to those who need it through no fault of their own. That's not right.

 

Someone else mentioned end of life care/heroic effort. I agree that this can be an area of waste. Americans do need to take a different view of end-of-life care (most people are completely ignorant of how end of life care works and the death process), but this is also an area where education is necessary. There are sometimes heroic measures taken, but responsible hospitals have stringent guidelines for this, and they are based on science and best practices, not rationing.

[kbutton]

In Canada the political/religious divide is much much deeper (and the country itself is quite secular).  I was listening to a story on public radio the other day about a politician who it was discovered had supported something pro-life before entering office - the politician stated that those were personal religious views that would not affect how he would act as a representative of his constituents.  And the idea of that makes perfect sense here.  I can't imagine that flying where I was from in the US.  

 

Another abortion issue in Canada - the conservative government gained power partially on the promise that they would not discuss abortion.  There is no federal law about abortion in Canada (it is legal up until birth).  When one conservative brought up a bill to have a discussion about when life begins , he jeopardized his status within the party.  The bill didn't go anywhere.  This is sooo opposite of how US political stumping works.  

 

The Canadian psyche is very different from the US psyche - and it is generally much more socialist, even with a "conservative" government in power.

 

Thank you for this perspective. I was wondering about some of this.

 

[Frances]

The thing with Canadian healthcare, IMO, is that it is reduced to the lowest common denominator. Sure we all get "free" healthcare, but low quality so that everyone can have it and some provinces are worse than others. I think it is a dying sacred cow that needs to be put out of its misery and come up with something better. What I don't know.

 

As to the documentary that started this thread, I'm sure it was heavily slanted as most docs are. I'm sure the makers didn't go out of their way to interview people who were upset with the system or who were even failed by the system.

 

I don't disagree that the documentary was likely slanted, in fact, I found some of the parts about the US system before the ACA to be quite sensationalistic. However, they actually did show many short interviews with numerous Canadians who had very long wait times for some procedures, joint replacements being the prime example. And of course they may have been completely cherry picking, but these people seemed to accept that as a trade-off for basic and critical healthcare for all.

 

Do you feel that surveys that show strong Canadian pride in their systems of universal healthcare are not valid and reliable and do not represent the views of most Canadians?

 

http://www.rcinet.ca/english/daily/interviews-2012/12-14_2012-11-26-what-are-canadians-proud-ofr/

[MrsJewelsRae]

I'm a Christian, lean conservative, and proudly Canadian. My brothers married American girls and we have a ton of American friends (we're an hour from the detroit border). I like our healthcare system and I do believe it is good for us to take care of our neighbour. It's not a perfect system and as far as lots of Americans being against national health care, I think it's a much more complex issue, I don't think it's necessarily completely selfish for someone to be against it, their motives may be different than just not wanting others to mooch off of them. That being said, I find great comfort in knowing that I can go to the doctor or hospital (or midwife if pregnant) and not have to check my wallet first. However, because of the drain on the system it often means very long wait times for finding a new doctor, going to specialists, and emergency room visits (I've frequently waited 6-8 hours in ER when I needed legitimate help in our small city hospital- we have a doctor shortage).

[MrsJewelsRae]

I would also add that the wait times for non emergent surgery are long, it is well known that if a person has $$ they go to the US to get their procedures done sooner and possibly to be treated at a better ranking facility.

[NASDAQ]

I don't disagree that the documentary was likely slanted, in fact, I found some of the parts about the US system before the ACA to be quite sensationalistic. However, they actually did show many short interviews with numerous Canadians who had very long wait times for some procedures, joint replacements being the prime example. And of course they may have been completely cherry picking, but these people seemed to accept that as a trade-off for basic and critical healthcare for all.

 

Do you feel that surveys that show strong Canadian pride in their systems of universal healthcare are not valid and reliable and do not represent the views of most Canadians?

 

http://www.rcinet.ca/english/daily/interviews-2012/12-14_2012-11-26-what-are-canadians-proud-ofr/

 

Canadians tend to associate Canadian healthcare with Canada and so they will tend to say that they like it, in the abstract. They'll also say they like bilingualism in the abstract, because they associate that with Canada too.

 

On the ground, disastisfaction with the system-as-is is rising. And no, I don't think that a lot of people are particularly happy with the level of trade-offs being made right now. An important healthcare decision was won in the SCC in Quebec on the right to private care because the care is so rationed there that it was an interference with the right to life. Private clinics operate illegally, when no such thing happened when I was a child.

 

 

Dissatisfaction tends to rise as people use the medical system more. That makes a certain amount of sense. It's one thing to believe in trade-offs in the abstract. It's entirely another to  be with your child, in pain, waiting for months on end because "it's a trade off for the greater good."

[brehon]

I'm still trying to figure out Jean's comment about those who have been covered for years who are notorious sometimes for wasting money by going to the ER for a common cold. Sorry, those people are the ones who are NOT covered by insurance. They can't afford an office visit . Obviously if you're a person who's been covered for years you'd probably already have a chosen doctor..,

I'm glad that our rinky dink town now has a non-emergency clinic for that type of problem. We have insurance, but have always had quite a long wait to get a visit. In my whole adult life, I don't think I've ever gotten in to see a doc without waiting at least 2 weeks or more. So the walk in clinic will be very useful to us.

ETA. Our town 's hospital and clinic are Catholic. I think it's by a charity called Sisters of Mercy. They are exceptionally caring and giving. I'm certainly not one who has many positive things to say about the Catholic hierarchy and its known abuses, but these local groups are beautiful.

I don't know what Jean meant. I know that in my area there are many free/low-cost clinics that stay open late on weekdays and are open most of the mornings and afternoons on Saturdays. Still, many people - who could get to these clinics either by car or public transportation - choose to utilize the ERs (either by driving or by ambulance) for non-emergent conditions.

 

I don't pretend to understand anyone's reasons for this and I'd rather people seek medical care early than wait until they become very sick. Still and all choosing to go to an ER for non-emergent conditions when other options are available and (in my area at least) easily accessed by most people puts a horrible strain on the emergency services and hospitals that serve those areas. This is turn puts an increased strain on the larger urban area.

[Audrey]

I realise you are in ON, NASDAQ, and if I lived there, I would be concerned and a bit pessimistic about provincial healthcare.  I live in a province with very low wait times for anything, and even though I'm very rural and we have very few docs, I can get in to see my GP  the same day I call or the next day at the latest.  I did have to wait 2 weeks to get an appointment to have a derm remove a couple of moles, but my GP had already biopsied them as benign, so that was not an emergency or urgent issue.  It is rare that I hear anyone complain about our system, even those living in the cities.  I do not see any "rise in dissatisfaction" from where I am sitting. 

 

My point is only that even within our country, the systems vary somewhat, so YMMV. 

[mommymilkies]

My eye is twitching. 

 

But I'll say this, as someone who has dealt with this failure of an American healthcare system as a patient AND healthcare provider, I will be more than happy to take Universal Healthcare.  I can not even fathom being against such a thing and I find it very selfish and ignorant to not want equal access to medical care for all people.  ALL PEOPLE.  Not just those who have money on hand. 

[liber]

I don't disagree that the documentary was likely slanted, in fact, I found some of the parts about the US system before the ACA to be quite sensationalistic. However, they actually did show many short interviews with numerous Canadians who had very long wait times for some procedures, joint replacements being the prime example. And of course they may have been completely cherry picking, but these people seemed to accept that as a trade-off for basic and critical healthcare for all.

 

Do you feel that surveys that show strong Canadian pride in their systems of universal healthcare are not valid and reliable and do not represent the views of most Canadians?

 

http://www.rcinet.ca/english/daily/interviews-2012/12-14_2012-11-26-what-are-canadians-proud-ofr/

I don't trust surveys all that much. I've participated in a few and the questions were very weighted or asked in such a way to prompt the person to answer in a particular way. I only skimmed the article you linked to but didn't see the actual questions people were asked for the researchers to arrive at their conclusions.

[Jean in Newcastle]

I'm still trying to figure out Jean's comment about those who have been covered for years who are notorious sometimes for wasting money by going to the ER for a common cold. Sorry, those people are the ones who are NOT covered by insurance. They can't afford an office visit . Obviously if you're a person who's been covered for years you'd probably already have a chosen doctor..,

I'm glad that our rinky dink town now has a non-emergency clinic for that type of problem. We have insurance, but have always had quite a long wait to get a visit. In my whole adult life, I don't think I've ever gotten in to see a doc without waiting at least 2 weeks or more. So the walk in clinic will be very useful to us.

ETA. Our town 's hospital and clinic are Catholic. I think it's by a charity called Sisters of Mercy. They are exceptionally caring and giving. I'm certainly not one who has many positive things to say about the Catholic hierarchy and its known abuses, but these local groups are beautiful.

All my comment meant was that someone who doesn't have to pay the big bills for the ER are not going to think as long and as hard about whether to go there as someone who needs to pay.  So money gets wasted because very expensive resources get used for care that doesn't  need those kind of resources.  I went for years to a low cost clinic that was on a sliding scale.  (And that is not the only low cost clinic in this area by a long shot.)   I realize that what is available is dependent on location - with urban environments probably having a lot more choice.  At least in this area there has been a big PSA type of campaign to get people to utilize the care that best fits their needs.  And it seems to be working.  

 

I have no problem with healthcare being available to everyone and indeed want it to be available.  I just think that waste of money partially by consumers and even more so by the government has had an impact and would need to be addressed before I would totally trust a proposal to fix this.  

[bolt.]

I don't know anyone willing to go to an ER unless they needed it. You sit in a waiting room for at least an hour (unless your case is really high priority, like a heart attack, or that sort of thing) and often much longer as other cases are appropreatly triaged ahead of you.

 

You sit in a plastic chair and gaze at a communal TV and expose yourself to everyone else's possible germs -- for hours. Then you get called in and recieve exactly the same care you'd get from any other type of clinic... it's just that you waited longer for it. What would motivate anyone to do that?

 

If the clinic is closed, or too far away, and that's about it.

 

Anyone who would do it for fun needs help with their mental health or something similar.

[Jean in Newcastle]

This was the very first article on the problem when I googled.  http://www.georgiahealthnews.com/2013/03/misuse-emergency-rooms-costly-avoidable-error/  I do not know where they got the figure of $4.4 billion in waste but that is a significant figure and is not something that I just made up.  

[Jean in Newcastle]

It still doesn't make sense, Jean. You said "people who have been covered for years who waste money by going to the ER". If a person who has been covered with insurance for years does go to the ER, then their insurance will either cover it, or more likely, not cover it. They will get a bill. Seeing that they pay for insurance, most likely they will deal with payments. I can not see a big enough number of people doing this as a way of gaining health care, if they knew they would have a smaller bill by seeing their doctor. "The people that don't have to pay the big bill"as you then say, would not be the ones with insurance. I think your complaint is in reality with those who could not/would not get any decent insurance and perhaps use the ER as their primary doctor. This is the group that the ACA was intended to help. Unfortunately, the Supreme Court allowed states to exempt themselves from extended medicaid, and many state legislatures have chosen to ignore the plight that millions of their citizens now face. But hey, it keeps people disgruntled and is easier to blame it on Obamacare. It's a win-win for the loser-lamakers.

OK - now I see where we are having a communication disconnect.  I think I wrote it weird.  What I meant to say was "people who have been covered by government assistance" (most typically Medicaid).  

[bolt.]

One thing that I imagine is helping with ER use is our telephone nurse line. One of the main things they are doing when you call is telling you whether or not you need an ER, an after hours clinic, or a regular appointment.

 

If you need the ER, they call ahead and inform the ER that you are coming, and tell them your symptoms etc, so that you skip some of the arrival procedures and might get seen sooner. This motivates people who know about it to use the nurse line -- for the efficiency. But if they don't need ER, they get reliably told what they do need instead. (Of course, they are free to go in to an ER anyways, and they say so, and encourage you to trust your own judgement, but people tend to trust nurses who tell you that you don't need it.)

 

Also, I don't think a doctor seeing you at a hospital would 'cost' any more than a doctor and nurse (or other personnel) seeing you anywhere else -- it's just that a doctor who works ER probably should be responding to more severe situations. (Possibly an ER doc would 'cost' a little more than a clinic doc. I don't actually know the pay scheme -- I just don't think it's a massive difference. Nobody says, "If you're going to be a doc, work ER because they make more." As a common knowledge sort of thing.)

[Jean in Newcastle]

ER docs (at least in the US) are specialists.  

[ChocolateReignRemix]

OK - now I see where we are having a communication disconnect.  I think I wrote it weird.  What I meant to say was "people who have been covered by government assistance" (most typically Medicaid).  

 

What is the evidence that those on Medicaid over use ERs relative to the uninsured or those who have private coverage?

[Jean in Newcastle]

What is the evidence that those on Medicaid over use ERs relative to the uninsured or those who have private coverage?

I don't have any.  I haven't looked.  So I'm not making dogmatic statements that they are the offenders.  But logically, they would have the least impact from doing so.  And the article I linked tied overuse of the ER for non-emergent reasons to consumer patients who don't have the consequence of having to pay for it.  But I don't know if they have concrete reasons for doing so.  I'd be interested to see if there are studies on ER usage and how that plays out geographically and in relation to coverage.  But I'm joining this conversation in a more lighthearted musing fashion and not in a "I'm going to win a debate" fashion.  

 

I do know, because I've seen the ad campaigns and the posters in the ER as well as other locations, that it has been enough of an issue for ERs to try and change it.  And I've seen more and more urgent care places pop up - a good trend, in my opinion.  

[a27mom]

I am an American, Christian, Healthcare worker, who has a significant amount of Canadian family (Toronto).

 

I am opposed to government provided universal healthcare because of the poor care I have seen my Canadian family receive, and the poor care we are forced to provide pt's on Medicaid (state run healthcare)

 

As a healthcare provider I am horrified by the pain, suffering, and hastened death my Canadian family experiences, due to the long wait time, and the "there isn't much we can do about it attitude". I was surprised on a recent visit to Toronto discover that my Canadian family has really no concept of how poor their medical care is compared to ours, (And I am referring to the care available to the poor in our area as well. ). I did not enlighten them on the issue, since one of the horrifying medical situations involved the recent death of a very young family member, and the pain is still quite raw. But it does haunt me wondering if she might be alive today if she had received care in the timely fashion she would have received it here. :(

 

It is difficult for someone who lives in an area where everyone has access to good healthcare no matter the income, to accept significantly lower quality care so people far away who refuse to adopt our model can have slightly better care.

 

We have several free clinics who work with the two local hospitals to provide free to extremely low cost ($1-3 a visit) care. The home care agency I work for provides care regardless of ability to pay, and most doctors and hospitals in our area with work with you on low cost payment plans or significantly reducing fees if you can not afford to pay. Unfortunately the ACA is threatening this very functional system since now those individuals who could avail themselves of free or low cost care may have insurance which requires copays etc... Free clinics simply can't afford to process through the insurance systems, and it is much more difficult, and in some cases illegal, for Doctors and hospitals to provide discounts to people with existing insurance.

 

The poorest care is received by those who receive State government care (Medicaid, NOT Medicare ). Our state simply doesn't pay it's bills so Doctors can only afford to serve a small number in there practice. And while our free clinics would love to serve these people, they simply can't afford to hire the staff to do the paperwork, or keep up with all the hoop jumping the state requires, and it could be a legal nightmare for them to knowingly to provide care to a Medicaid patient, without billing Medicaid. Although I will say even this care is superior or as good as the care my Canadian relatives get.

 

I am all for everyone having access to affordable healthcare. But the thought of the government being primarily responsible for that healthcare gives me the chills. Also, it seems to me that those who can afford healthcare should pay for it in full. Thus providing better healthcare for those who can't afford it. Most people I know aren't opposed to the government assisting with basic healthcare for the poor, "the safety net". They are opposed to the government attempting to "fix" the system by providing low cost healthcare for the rich.

 

Oh and most people I know who are opposed to government run universal healthcare, are in favor of reform for our messed up insurance system, but not the current reforms.

[SeaConquest]

Except I wasn't talking about extreme measures for end-of-life care for the elderly. Those kinds of "easy" savings have already been made. I'm talking about waiting 2+ years to get your kid's scoliosis fixed. We have the longest wait times in the OECD.

 

My husband and his family have all had similar wait times (2-3 years) for surgeries in Quebec. My husband was in pain for quite a long time because of it. He is now a dual citizen, but is still often amazed by the comprehensive and speedy care that he receives in the U.S.

 

As an aside, I had a severe asthma attack when I was visiting Quebec one summer. My meds were not working to resolve the issue and things were getting worse. We went to the ER. They triaged me very high (according to my husband), but still told me that the wait would likely be close to 24 hours. They also required a $1500 deposit before they would treat me (even though I had insurance that covered me while out of the country). In the U.S., an ER has to treat you no matter where you are from or what you can pay. I found it interesting that Canada, or at least Quebec, did not share the same philosophy. We ended up having a doctor friend phone in a script for a steroid for me to a Canadian pharmacy.  

[Rose in BC]

I agree with Audrey that maybe services are different in different parts of Canada. I live in a rural, far from urban centre but cannot complain about our services. One of my children causes me to be a frequent flier at the ER. We are always well served. And I am thankful for the coverage we have.

 

My dad died of leukaemia many years ago. His treatment required him to be in isolation in cancer clinic for months. Again, we didn't go bankrupt over his illness. (And btw, he went from his dr's office where he thought the dr would tell him he had flu, by ambulance to hospital and next day he was admitted to cancer clinic.)

 

There are wait times for elective surgery but emergency stuff, in my experience , has always been dealt with quickly.

 

The system isn't perfect but it's worked well for us.

[liber]

My husband and his family have all had similar wait times (2-3 years) for surgeries in Quebec. My husband was in pain for quite a long time because of it. He is now a dual citizen, but is still often amazed by the comprehensive and speedy care that he receives in the U.S.

 

As an aside, I had a severe asthma attack when I was visiting Quebec one summer. My meds were not working to resolve the issue and things were getting worse. We went to the ER. They triaged me very high (according to my husband), but still told me that the wait would likely be close to 24 hours. They also required a $1500 deposit before they would treat me (even though I had insurance that covered me while out of the country). In the U.S., an ER has to treat you no matter where you are from or what you can pay. I found it interesting that Canada, or at least Quebec, did not share the same philosophy. We ended up having a doctor friend phone in a script for a steroid for me to a Canadian pharmacy.  

 

 

 

I think in Nova Scotia you have to pay something upfront too.  I vaguely remember my aunt that lives in Texas, mentioning that one year when she was home. 

 

And yes, wait times can be long.  My mom had skin cancer on her nose and it was a couple of months to see a dermatologist to have it removed.  In her opinion, that wasnt a long wait.   I'm the US now and wanted to see the dermatologist.  I just picked up the phone and had an appointment the next week.  I also saw a dermatologist in Canada.  I had to be referred by my GP.  That took a few months and I had to pay out of pocket.  Provincial healthcare didnt cover it nor did my husbands insurance plan from his work.  Also, sometimes your GP won't refer you to a specialist.  I wanted this same GP to refer me to a dermatologist to look at a couple of moles.  He wouldn't do it.  He removed the moles himself and he was a butcher about it compared to the dermatologist who removed a mole here in the US.  The other thing that doctors seem to be doing, at least in Manitoba is only listening to one complaint/concern a visit. If you are lucky the doctor might hear one major and minor concern per visit.  So you are out of luck if you have a lot going  on that you think might be related.  An elderly man has brought a lawsuit against the Manitoba government claiming that policy of hearing concerns lead to his wifes death.

 

Oh and this past weekend my brother and his girlfriend just had a baby.(New Brunswick)  She wanted some pain relief.  The gave her some morphine and sent her home to rest.  The nurses said she could only stay in the hospital is she didn't take any pain relief.  Apparently it is hospital policy.  Needless to say, my mom was livid.  I have had babies in three different provinces, hospital and home births and I never heard of this.    I am beginning to believe my family when they say healthcare in the Maritimes is a$$-backwards.  I won't get started on the poor care my grandmother and other family members have received.

[MistyMountain]

It is difficult for someone who lives in an area where everyone has access to good healthcare no matter the income, to accept significantly lower quality care so people far away who refuse to adopt our model can have slightly better care.

I don't have access to quality health care and I have insurance at the moment. I went without for way to long and my kids went without for a year and I was terrified that entire time. Charity care had the same low income guidelines as the state insurance for the kids that we just squeaked over the limit for. Private insurance wasn't anywhere near affordable. The minimum premium was over 1000 a month with at least a 10,000 deductible and that before you fill out the information they find out your little one had to go to the hospital once and you had a procedure a few years ago and charge you more. MY husband had a job that took care of everything just barely except that because it was a small company. We went without because we didn't work for a big company. Now he at a slightly bigger company so we get mediocre coverage with a pretty high deductible. The best health coverage we ever had was the brief period my kids were covered by state insurance.

[Frances]

I have to say I've definitely learned a lot from the replies to my original post. I certainly didn't realize the experiences with universal healthcare were so varied across the different provinces in Canada. I've been googling different research studies that compare healthcare systems throughout and the world and it turns out that in general, neither the US nor Canada rank near the top. There are all types of different studies using various measures of quality, price, efficiency, effectiveness, etc. In general, the most highly rated programs are in Asian and European countries, although Canada consistently outranks the US. 

[a27mom]

I don't have access to quality health care and I have insurance at the moment. I went without for way to long and my kids went without for a year and I was terrified that entire time. Charity care had the same low income guidelines as the state insurance for the kids that we just squeaked over the limit for. Private insurance wasn't anywhere near affordable. The minimum premium was over 1000 a month with at least a 10,000 deductible and that before you fill out the information they find out your little one had to go to the hospital once and you had a procedure a few years ago and charge you more. MY husband had a job that took care of everything just barely except that because it was a small company. We went without because we didn't work for a big company. Now he at a slightly bigger company so we get mediocre coverage with a pretty high deductible. The best health coverage we ever had was the brief period my kids were covered by state insurance.

Question, you said you don't have access to quality healthcare. So do doctors and hospitals turn you away because of your insurance or inability to pay?

 

Or is quality healthcare too expensive, so you are unwilling to access it?

 

I do agree that the insurance system is really messed up, and the current plan to force more people into a messed up insurance system is not helping. And it is nearly impossible for doctors/hospitals etc. to offer reduced rate care to people with insurance. (Though once someone has demonstrated inability to pay after the fact there are usually more options to help).

 

Like Canada we do vary by state since the health insurance industry has been largely state regulated. I do know some (probably most) states run their Medicaid system much better than my state.

 

But my Canadian relatives truly have poor access to healthcare, because the wait is so long. I had a family member die 2 wks before their follow up appointment to start treatment, the problem they died from had been identified 10 months previously, but it took that long for them to schedule 1 test and a follow up appointment.

 

It is interesting though to read that this varies by region in Canada, my experience is mostly limited to Ontario. Though it is not terribly reassuring since I live in a particularly corrupt, poorly run state.

[Aelwydd]

What no one is talking about is that, regardless of how a country decides to deliver health care, either by privatized industry or public, is dwindling resources.  On a global scale.

 

Health care requires a mega-sh!t-ton of energy.  It requires energy to heat, cool, and power hospitals, clinics, facilities. Power to their lights, their computers, their medical equipment, and so forth.  It requires tons of petroleum-based plastics, such as needles, latex gloves, tubing, basically anything that comes packaged and sterilized comes in...plastic. It takes tons and tons and TONS of water.  Water to wash, water to go into the production of the above plastics, water to clean, to drink, etc.  It takes tons of energy to produce MEDICATIONS. It takes almost an endless supply of energy to produce the food, formulas, special feeding diets for countless patients.  It takes a tremendous amount of resources to train, retain, and continue to retrain the medical professionals providing care.

 

That's just the tip of the iceberg.

 

With 7 billion people in the world, and only 360ish million of them in this country, we are already pushing at the limits of what OUR own natural resources can provide for us.  We supplement what we need by buying (cough, taking, cough) oil from other countries. 

 

As more and more people seek to raise their standards of living nearer to what we, ourselves, enjoy, that means they will be putting up more and more of a protest for their fair share of the world's supply of oil, fresh water, and so forth.  Health care is a commodity now. 

 

Some countries seek to offset the highly variable market by controlling costs and instituting a public system.  This has varying degrees of success. 

 

However, we are all running towards the same "goal"--and this keeps me up at nights sometimes--there is not enough for everyone to get access to that high standard of health care, as it is practiced now.  And meanwhile, we are all using up the fresh water and fouling up the air and earth in our relentless pursuit of these resources.  In the end, we'll have whole swaths of areas in the US, inhabited by poor, sickly, cancerous, neurologically damaged people who were made sick by the poisoned environment, and who were locked out the market by ever climbing costs, long ago.

 

It'll be the same story in a lot of other places, unless we get our collective head out of our arse, and figure out that clean environment, good, real food that is not Frankenfood, clean water, and a balanced life style are the best protection against disease and illness.  That less is better, and that we should be learning about holistic remedies, rather than medicinal solutions for every ailment.

 

People are so stressed and overworked and underpaid in this country, that many can't afford to eat well, can't afford to take mental health breaks--otherwise known as vacations--can't afford to live in cleaner neighborhoods, away from gas drills, mines, industrial plants, polluted rivers and streams, and dirty air, and the problem is always framed as "Accessibility to health care."

 

Well yeah!  When everyone is needing the same thing, demand goes up, and so does price.  Availability goes down!  We could address the ROOT of the problem, which is really a series of co-morbidities all tied up in national epidemics, or we can keep doing what the very, very few folks--I call them the Masters of Monopoly--who benefit from this scheme want--and that is to keep fighting each other for scraps thrown to the bottom of the barrel. They are the ones who hire the politicians and the health care industrial leaders to act as Gatekeepers, determine which groups get to pass through and which are just cogs for the machine.

 

 

 

[Aelwydd]

Question, you said you don't have access to quality healthcare. So do doctors and hospitals turn you away because of your insurance or inability to pay?

 

Or is quality healthcare too expensive, so you are unwilling to access it?

 

I do agree that the insurance system is really messed up, and the current plan to force more people into a messed up insurance system is not helping. And it is nearly impossible for doctors/hospitals etc. to offer reduced rate care to people with insurance. (Though once someone has demonstrated inability to pay after the fact there are usually more options to help).

 

Like Canada we do vary by state since the health insurance industry has been largely state regulated. I do know some (probably most) states run their Medicaid system much better than my state.

 

But my Canadian relatives truly have poor access to healthcare, because the wait is so long. I had a family member die 2 wks before their follow up appointment to start treatment, the problem they died from had been identified 10 months previously, but it took that long for them to schedule 1 test and a follow up appointment.

 

It is interesting though to read that this varies by region in Canada, my experience is mostly limited to Ontario. Though it is not terribly reassuring since I live in a particularly corrupt, poorly run state.

Then, there is my friend from a few years ago. She found a lump in her breast in October, but daren't say anything because her husband, who'd been laid off that year, was newly employed, and his insurance wouldn't cover anything until January 1st. If she was diagnosed before then, it would have been a pre-existing condition, and therefore not covered at all by insurance.

 

She waited, the lump grew. Her mother had died of ovarian cancer. She was very scared.

 

In January the next year, she went in. Lump biopsied, and it was indeed malignant. But, she's got insurance right? So now she's good?

 

 

Wrong.

 

They wouldn't touch her, would begin ANY treatment until she and her husband first ponied up the full deductible for their insurance--$2500. Two weeks later, finally they started treatment. It had spread, and she required a double mastectomy.

 

Do you understand that while it sucks to wait, at least in Canada, CANCER does at least get treated? That a person's lack of ability to pay is not held like some kind of blood ransom over someone's head while seeking treatment for a life-threatening disease?

 

At the same time this was happening, another friend of mine, who lives in Alberta, found out her mother was diagnosed with breast cancer. Her mother's cancer was diagnosed and first treatment begun within 2 weeks of her mother discovering the lump!

 

Of course, we can trade anecdotes all day long, to demonstrate the superiority of one over the other. But, that's highly subjective, which is why health measures are much more informative, such as average lifespan, neonatal and infant mortality rates, maternal mortality rates, cancer survival rates, and so forth.

 

Canada's system is definitely stressed and has issues. It still manages to out perform the US in almost every category, and for a hell of a lot less money.

 

I would say it is definitely desirable for all nations to start reconsidering their health care systems, from standards of care, to how sustainable they are in the long run, because we are all going to hit that brick wall of sky rocketing costs.

 

The questions is, where would you rather start-- in the already, "We're paying Lexus prices for Kia care" brand that you have here in the US, or do you want to start with something at least somewhat more workable, like Canada's system?

[Laura Corin]

I think that two different things are being confused in this discussion: the amount being spent on healthcare and the method of its delivery.  Currently, Canada spends about half of the US levels on healthcare.  If Canada, as a democratic nation, decided to spend at US levels, then it probably would have no waiting lists.  That's not a question of system - just of what each country decides to spend.

 

L

[MistyMountain]

Question, you said you don't have access to quality healthcare. So do doctors and hospitals turn you away because of your insurance or inability to pay?

 

Or is quality healthcare too expensive, so you are unwilling to access it?

I guess they would help for certain emergencies but if one of my kids developed a chronic condition or cancer then no they wouldn't just do ongoing treatment. They would treat us for some stuff but we would have lifelong huge debt. I wanted more then anything in the world to have insurance for my kids. It wasn't an unwillingness. I was so depressed at that time simply from a lack of insurance for my children.

[Jean in Newcastle]

I was very very happy with my HSA account.  I don't have it now because of ACA but I wish that I did.  I have taken out small loans to take care of medical needs.  I barter all the time with my doctors.  I have a doctor who has agreed to charge me a monthly fee and I can see him as much as I want that month for certain chronic problems.  (Actually "agree" is not correct - he offered me this when he saw that I came in as much as I could afford but was still left in pain much of the rest of the time.)  We're going to another doctor next week that I've asked ahead of time if I can pay him in installments.  He doesn't normally do that but since I asked up front and did not push, has agreed.  I've gone to clinics with sliding scales.  The doctors were very good doctors by the way (except for one lech who I reported) who work at these clinics in exchange for money off of their student loans.  I do not go to the doctor for sniffles.  I do a lot of research and have found Dr. Hive to be very helpful.  When I do go I go to good doctors that I've researched and who have been (for the most part) great caring people who give prompt care.   Our medical needs mean that medical care is a big item in our budget and we've done without a lot of other stuff because of it. But c'est la vie.  

[bolt.]

These things are terribly complicated, and all the systems have deficiencies, flaws and outright stupidities associated with their execution in the real world. But...

 

This thread was asking how people's philosophies seem to differ specifically between the US and Canada.

 

In my opinion, a system can be flawed: and therefore create bad outcomes that might be discribed as unjust -- but that differs from a system that isn't oriented towards fair dustribution (or near it) in the first place.

 

If its not the case that all the people in a country can/will recieve excellent care all the time -- the question of justice focuses my mind on "Who experiences the problems, and why?"

 

In Canada, it's location factors, combined with blind bad luck that gets a person into a situation where their care is poor -- or else all the people are getting the same level of not-great care in a generally even handed fashion. These factors to me seem "fair" -- when it sucks, it sucks, but no one was singled out or chosen for bad care.

 

In the US it seems to me that people are experiencing the lesser end of care, of no care at all for actual, identifiable reasons: perhaps poverty, or that class where ends meet, but medical expenses are still terrifying. This feels like the poor (perhaps particularly the poor who also aren't intelligent enough to do research and seek options and think outside the box) are chosen by this social system to be the ones who recieve lesser care -- so that others recieve greater care.

 

Care is distributed from excellent to inadequate 'roughly by wealth' -- rather than 'generally randomly' and that's a philosophical difference that matters to me.

[kbutton]

I'm still trying to figure out Jean's comment about those who have been covered for years who are notorious sometimes for wasting money by going to the ER for a common cold. Sorry, those people are the ones who are NOT covered by insurance. They can't afford an office visit . Obviously if you're a person who's been covered for years you'd probably already have a chosen doctor..,

 

In our community, the people going to the ER for a cold are folks who are covered by Medicaid (and have been before the ACA), and the patient does not pay a dime.

 

Many people who have insurance (private or Medicaid) don't have a primary doc for many different reasons. Some get sick so rarely that every time they go, the doc treats them like a new patient, or they can't get a quick appointment because the office can't find their file. Many of those folks do use urgent care, not all of them go the ER. Having a primary doc or not having a primary doc isn't always tied to insurance. Some of them see a specialist for allergies, for instance, so they access their primary doc very rarely.

[kbutton]

I don't know anyone willing to go to an ER unless they needed it. You sit in a waiting room for at least an hour (unless your case is really high priority, like a heart attack, or that sort of thing) and often much longer as other cases are appropreatly triaged ahead of you.

 

You sit in a plastic chair and gaze at a communal TV and expose yourself to everyone else's possible germs -- for hours. Then you get called in and recieve exactly the same care you'd get from any other type of clinic... it's just that you waited longer for it. What would motivate anyone to do that?

 

If the clinic is closed, or too far away, and that's about it.

 

Anyone who would do it for fun needs help with their mental health or something similar.

 

In our community, people come for the free movies in the rooms and bring all of their relatives. I am NOT KIDDING. And many of them are not mentally ill. Some blatantly state that they are there to get stuff for free.

[kbutton]

It still doesn't make sense, Jean. You said "people who have been covered for years who waste money by going to the ER". If a person who has been covered with insurance for years does go to the ER, then their insurance will either cover it, or more likely, not cover it. They will get a bill. Seeing that they pay for insurance, most likely they will deal with payments. I can not see a big enough number of people doing this as a way of gaining health care, if they knew they would have a smaller bill by seeing their doctor. "The people that don't have to pay the big bill"as you then say, would not be the ones with insurance. I think your complaint is in reality with those who could not/would not get any decent insurance and perhaps use the ER as their primary doctor. This is the group that the ACA was intended to help. Unfortunately, the Supreme Court allowed states to exempt themselves from extended medicaid, and many state legislatures have chosen to ignore the plight that millions of their citizens now face. But hey, it keeps people disgruntled and is easier to blame it on Obamacare. It's a win-win for the loser-lamakers.

 

People who are on Medicaid (in our area) can go to the ER for free, and so they do. They aren't going to choose the cheaper option because one option is NOT cheaper than the other for them. Both options are the same cost for these folks.

 

[Azalea]

I was very very happy with my HSA account.  I don't have it now because of ACA but I wish that I did. 

 

Hi Jean, I'm American so subject to ACA. I still have an HSA account. Have these been outlawed by the ACA and somehow I failed to notice? Anyone?

[Jean in Newcastle]

Hi Jean, I'm American so subject to ACA. I still have an HSA account. Have these been outlawed by the ACA and somehow I failed to notice? Anyone?

No, not outlawed.  It's just that in my state they've made it so that the HSA offerings are no longer affordable or desirable for a family like mine.  They increased the premiums and raised the deductibles.  What I have now under ACA is better than what the HSAs offer now in my state but worse than what I had before the ACA with my old HSA.  Does that make sense?

[Azalea]

No, not outlawed.  It's just that in my state they've made it so that the HSA offerings are no longer affordable or desirable for a family like mine.  They increased the premiums and raised the deductibles.  What I have now under ACA is better than what the HSAs offer now in my state but worse than what I had before the ACA with my old HSA.  Does that make sense?

 

Hi Jean, I think this might be a failure of acronyms!! My HSA is a health savings account, it's not insurance or anything I pay for.  We put pre-tax money in (I think up to $6500 per year)  and pay for our medical expenses out of this account rather than out of a regular checking account. I do appreciate the convenience of having money set aside for medical expenses. 

[Jean in Newcastle]

Hi Jean, I think this might be a failure of acronyms!! My HSA is a health savings account, it's not insurance or anything I pay for.  We put pre-tax money in (I think up to $6500 per year)  and pay for our medical expenses out of this account rather than out of a regular checking account. I do appreciate the convenience of having money set aside for medical expenses. 

The rules in my state are that you open a Health savings account at the bank only if you have a High deductible insurance policy that goes with it.  The high deductible insurance premiums and all other costs for actual medical care came out of the HSA account.  

[LMV]

The rules in my state are that you open a Health savings account at the bank only if you have a High deductible insurance policy that goes with it.  The high deductible insurance premiums and all other costs for actual medical care came out of the HSA account.  

 

Are you sure you can't set up a HSA even if you have an ACA compliant plan?  Admittedly we're not in your state but we have done this.  I suppose depending on your state tax laws it may be that the HSA contributions are still subject to state tax even if they are tax free at the federal level. 

[Jean in Newcastle]

Are you sure you can't set up a HSA even if you have an ACA compliant plan?  Admittedly we're not in your state but we have done this.  I suppose depending on your state tax laws it may be that the HSA contributions are still subject to state tax even if they are tax free at the federal level. 

I checked my bank's website and it says that an HSA has to be matched with a high-deductible health plan.  In my state, there are only a few high deductible health plans that are ACA compliant.  The one I had up until the end of last year was not compliant and they discontinued it.  The ACA compliant ones are so high of a deductible that it no longer makes financial sense for me to get them because of my health needs.  If I was a "healthy as a horse" person who never went to the doctor and only needed it in case of a catastrophic injury or illness, then it would still make sense to get one, in my opinion.  

[a27mom]

Hi Jean, I think this might be a failure of acronyms!! My HSA is a health savings account, it's not insurance or anything I pay for. We put pre-tax money in (I think up to $6500 per year) and pay for our medical expenses out of this account rather than out of a regular checking account. I do appreciate the convenience of having money set aside for medical expenses.

You can only have an HSA account if you have a qualifying High Deductible Insurance plan. What you are describing is a flexible spending account for healthcare.

[Jean in Newcastle]

You can only have an HSA account if you have a qualifying High Deductible Insurance plan. What you are describing is a flexible spending account for healthcare.

Yes, now that I don't have the HDHP, I have switched to a FSA (flexible spending account).  There's more alphabet soup for you!