Free/universal healthcare (non Americans)

1) Canada.

2) You choose your family doctor - but there's a shortage of family doctors and some people are struggling to find regular ongoing care & relying on drop in clinics. The cancer agency in Vancouver now has Nurse Practitioners to provide ongoing care for those who don't have a family GP. For an oncologist, you are kind of assigned but you can make requests and changes and get 2nd opinions. But the cancer care system in my province is highly integrated - all the cancer centers work together from the same guidelines and any cases that don't fit into neat categories are discussed at regular tumor board conferences so my sense is there is not much variation in treatments. I had a choice of surgeons and endocrinologists etc.

3) For me they have been. I'm in a large metropolitan area though. In some smaller towns there are delays and levels of service are not the same. Everything for me has been smooth and quick, even during covid.

4) in my group of friends & family, yes. There is also pretty broad support for expanding healthcare to include a pharmacare program (currently drugs are not covered unless you are on social assistance and even then, not always; or if you have private extended health insurance through an employer. Cancer therapy drugs are *mostly* covered but the drugs to deal with side effects are not.Also, new cancer drugs are often not covered.) and also some coverage for dentistry

5) best - we don't go bankrupt for medical care whereas I understand it's one of the leading causes of bankruptcy declarations in the US. Worst- things take a while to get approved (we're often a couple years behind the US for cancer drugs for ex) and some are approved but NOT covered by the gov't. Nationwide, decisions on whether a cancer drug will be recommended for financial coverage are based on recommendations that will benefit the most people. So a very expensive drug that only helps a few and only a bit, will likely not get approved because it's better to provide other, more effective therapies to more people. Needs of the many outweigh the needs of the few....
And again, on the worst side - wide disparities based on region. Remote areas of Canada have greater health challenges and poorer services.

1. What country are you from?

Currently in the UK; have used both NHS (public, universal care provider) and private services

2. Are you able to choose your doctor and hospital or are you assigned to one?

Under NHS - I was assigned to a hospital for my initial dx, and would have had surgery there had that been the proper route. I was not happy with the surgeon OR the hospital, which was miles from my house, and I felt it was of questionable cleanliness. I was then reassigned to a different hospital for oncology, and reassigned to a new oncologist who I only saw once, instead mostly seeing junior oncologists/researchers/registrars. Appointment times were down into the 8 to 5 minute range and every new oncologist meant they had no idea who I was or my concerns. It drove me nuts so I switched to private care, where I was able to choose my oncologist and hospital and I see JUST HER every month, so she know me as a person and I feel much more at ease opening up to her.

3. Are tests and results scheduled in a timely manner, like two weeks?

Depends - my scans were moved from 3 to 4 months right away, mostly due to Covid pressures. Results were hit or miss, I once waited almost a month for the outcome of some scans. At diagnostics it took two weeks to find out I had cancer (for sure), then another two weeks to find out it was terminal, and then another 8 weeks before I started treatment. Under private treatment I use the same facilities but am "bumped to the head of the line" - my scans are now scheduled when they are convenient for my schedule (end of day), I can make changes, and my results are done within 24 hours. The same doctors work in the NHS and private systems as I don't think they can have hospital privileges without agreeing to see a certain percentage of NHS patients.

4. Do people generally agree that the higher income tax rates are a fair trade for the medical benefits? (I only ask this because I can't see how it would be possible to provide it without raising taxes)

The NHS is essentially a state religion in the UK and the link between tax payments and affording the health service has been broken. There is very much a sense of entitlement to "our NHS" - you get a lot of stories of timewasters who are drunks in the ER at 3 am every Saturday, or people going to the GP because their toe hurt, that sort of thing. Similarly you get people who "don't want to waste the NHS time, its just a little thing" when it actually is something that SHOULD be checked out, but there is this perception that the all-holy NHS can't cope year after year after year so we must all support it by... not using it?!

It is free at point of access so people push that to the limit. I am in a high tax bracket and pay over 40% of my salary on taxes, a lot of which goes to supporting the NHS. That is before you account for the local services monthly tax and the 20% VAT tax on everything else. My workplace 100% funds my medical insurance and I have no other deductibles and maybe a small copay (I had to pay the difference for my genetic testing - a whole £14). As a cancer patient, any medicine prescribed for me is free - so my letrozole or amoxicillan or whatever the GP may prescribe is always free, as are my Ibrance and other drugs. You can access other drugs in the private system as there are certain equations used to determine if a drug is useful to offer to the wider population.

Is it a fair trade? I think a small form of personal contribution to access services (say £10 for a GP visit, or £100 if you are using the ER as a drunk tank on the weekend) would help encourage people to take care of themselves better, fund improved services and access, and get people to realize that health care isn't free and no, the NHS can't just always patch you up and off you go. Many people in this country don't pay any form of income/contributory tax, so if you are stuck in the higher tax bracket, but below the super rich, you are paying a lot of money in contributions to the health system for others who won't take care of themselves (not everyone is like this, but you see the disincentive).

A small fee could also help fund better preventative care - mammograms dont start here until 50 (even then is every 2 years), its every 3 years for a PAP (which doesn't include breast/pelvic exam). The GP system acts as a gatekeeper into the NHS services so if you are "too young" for cancer they are more likely to put you off rather than refer to get something checked out. It took me almost four weeks to get my initial appointment to be seen for my breast lump. GP offices are not great - usually somewhat shabby with older equipment and I have never EVER had a single GP actually touch me. I had one diagnose my back problem from sitting behind a desk.

I am American and wanted to share my perspective. Countries that have national healthcare systems are usually happy but most I know freely acknowledge that it is not perfect. In the US, we have a tangled patchwork of ways to get medical coverage. Wait times for appointments, tests and results are all over the place and the reality is that if you have a very good insurance plan, you are often served more quickly and given more options. If you don't have insurance or have a plan that doesn't cover much, you're in for many more delays and fewer, if any, choices. Bottom line? If you have the money you can get great care, if not your care choices become limited. I have been fortunate to have very good insurance but would gladly “give up" some of the conveniences I've enjoyed sothat everyone can get decent medical care. So many other nations have figured this out. Why can't we?

illimae, I learned a lot about healthcare around the world in a couple of Facebook groups about health care policy, which have since gone dark, unfortunately. They were not specifically focused on cancer care, either, but still incredibly informative.

Kaiser Health News (khn.org) is a good source if you really want to dive in deep to US health policy news.

I would love to hear more from people here about cancertreatment in other countries, especially Germany and Switzerland. Even though, in the end, it is true, whatever continues to develop here is going to be unique to the USA, building on our current health care system and within the bounds of what is possible politically.

I am German, but have lived in the US for some 15 years now, and when I was still living and working in Germany (I left Germany when I was 35) I hardly ever was sick. So my experience is limited, yet I have 2 80 year old parents and my sister and her family still live in Germany and I know what they experience.

In Germany, we have 2 types of health insurance, one is "universal" and one is privat. Every person has to have one or the other. If your job is well paying you can choose the private insurance otherwise you have to have the universal. Even within the universal, there are several policies but they are rather similar. If you don't have a job and no means to pay for the health insurance via savings or pension the "Bundesversicherungsanstalt für Arbeit" (a governmental organization) will pay it for you.

I calculated the costs for universal health care based on a 3,000.- EUR salary before tax (see below). The employee pays 1/2 and the employer the second half. In total, the monthly cost is 290.25 EUR (and the same amount is paid by the employer). The price is calculated based on income. The more you earn the more you pay (currently 15% of your income before tax). There are no deductibles and the patient never sees any bill. One can go and see any Dr. at any time. There are no in "in network" or "out of network Drs". Also as far as I know you don't need a referral for a specialist. However, it sometimes can be a wait times for specialized Drs. That's were the private insurance comes in a bit better, Drs. usually prefer private patients because they can charge more for their services. When I was still working in Germany, I had a well paying job so I chose the private insurance, which has a slightly higher monthly premium and a deductible (which I could choose on my own). The higher the deductible, the lower the monthly cost. When I needed an appointment and I was told the next available would be in 3 weeks, I said I was a private patient and so my next appointment was usually available within 1 week. Usually one can get an appointment within 3-4 weeks for any sort of Dr. even as a universal health patient. If it is an emergency, one can get it much quicker, or obviously can go straight to the hospital.

My mother has universal health insurance, but she has a private "supplement", which allows her a few extra perks, such as single rooms in the hospital and extended sick pay, and for her, because we live at the Swiss border, she can also go to Switzerland for treatment if she wishes to do so.

From what my parents tell me, in recent years there are fewer and fewer small local practices and more and more large centers, which means longer travel for them and navigating new places. For example, she told me that in our home town of 30,000 people no longer has a local gynecologist. Local family Dr. getting rarer and rarer too, many also prefer to work in Switzerland where salaries are higher. Opticians the same thing. My mom's optician retired recently and none of the other close-by opticians would take on any new patients when she called. In this case, one can call the insurance and they have to find a Dr. for you. They will then make the appointment. Drs. cannot refuse a patient, at least in theory.

I guess the biggest thing right now in Germany is the tendency that the small local offices disappear. But on the other hand, large new modern centers arise, but they require more travel and maybe for the elderly not as convenient. Germans like to do things local :-)!

But overall, Germans are very satisfied with their health care, I have never met anyone who had any dept from paying of medical bills, no matter what sickness they had. Also the premiums are universally accepted. The more you earn the more you pay seems fair to everyone. It has always been that way, so noone really questions it.

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Yes, Mae - great topic. I am on Medicare and chose to stay with the traditional (original) plan rather than move to an "advantage" plan when they were developed.

With traditional Medicare, I also pay for a Medigap policy that covers the 20% Medicare doesn't pay. Between the two policies, I have not paid anything else except the yearly deductible that was $183 last year. That said, there are several Medigap policies you can choose with different rules. Example - some require a $20 deductible for each visit. But there are no "gatekeepers" and I don't need a referral for any kind of specialist.

In 11 years I have never found ANY docs who wouldn't accept Medicare. The only exception was my old PCP who converted to be a "concierge" doctor. You paid something like $1500 each year (in addition to regular costs) and were guaranteed a personal answer or appointment immediately. Needless to say, I found a new PCP. I live in a big city so finding docs who accept Medicare may be different in a rural area.

The Advantage plans cover more services for less money, but usually requires you to be part a specific network. If the doc you like isn't in that network, its not covered. And you have to have a referral from a primary care physician before you see a specialist. Hopefully I'll be able to continue with my current plan and have treatment wherever I want.

Not mentioned yet is Long Term Care. When those insurance policies were instituted, I was unable to afford the premiums. And premiums have continued to increase exponentially, which most of us didn't understand to be part of the original deal. Many people have dropped out as premiums increased. I'm still unable to afford Long Term Care insurance. Medicare does NOT pay for nursing homes for very long - 90 days maybe now?? And it does not pay for home care. I have no idea what I'll do when I can no longer take care of myself. I just keep sticking my head in the sand.

Sorry - didn't mean this to be so long. One last note - I have some 50 year old friends who took early retirement and moved to Panama. They love the health care set up there. Of course neither has ever been sick yet.

I have been very fortunate in my lifetime of always being covered by medical insurance - my parents when I was a child until young adult, then when I was a young, single adult employer based coverage, then thru my husband's employer based coverage when I got married. Although at some point in time my husband got a single policy and I covered myself and our two girls on a family policy because it was cheaper for us to do that.

Now I have also been fortunate in that I was relatively healthy when I was younger other than an occasional cold, virus only going to the Dr for my annual wellness check up.

But once I turned 51 my breast cancer diagnosis, surgery and treatment changed all of that for me. Once again, I am fortunate that I am covered under my employer based health insurance plan, all of my dr's are in network and I have managed to be able to pay my co-pays and very little more. (One of our family physicians became concierge practice so had to switch to another PCP as our family could not afford her fees)

Now what frightens me is what my 30 yr old daughter is going through with getting medical coverage. She makes too much money to qualify for help with expense of coverage but cannot afford to buy a policy! She did pay for the cheapest ACA policy which was $35 per month but $8000 deductible! She reasoned that she could not afford the deductible so discontinued that policy! She has not been to the dr since age 26 when my insurance stopped covering her. I fear for her and others in the same situation as her. She has gone to Urgent Care a couple of times for minor things and luckily a mental health professional will see her every 3 months for $80 to prescribe her depression medication (Good RX). The USA will have to come up with some type of public health option for people in this situation.

My younger daughter is disabled and over age 26 but my meducal insurance has included her on my policy for life although she still gets Medicaid but my insurance is her primary so private drs will still see her.

Celand

SondraF, I think in my province verzenio/fulvestrant didn't get approved till May 2020. It's back to the "needs of the few vs needs of the many" calculations that publicly funded health plans have to make. It's frustrating when it's *us* that are the few. I heard in chemo room gossip last time I was there that a gyne cancer pt was driving over to the US for trodelvy for something like 20k/month. Eeek.