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The death of convergence theory

Canadians and Americans aren’t so different: Tim Hortons and Dunkin’ Donuts, poutine and disco fries, professional hockey and professional wrestling -- there’s some truth behind that “51st state” joke. But despite our similarities, there’s a glaring difference between us that we can’t seem to reconcile: health insurance.

This year, in which a Canadian federal election preceded the American one by just three weeks, serves as a case in point.

Throughout the Canadian campaign, the mere mention of expanding the role of private insurance set off public apoplexy. During the American campaign, a Canadian-style single-payer system has been deemed equally ludicrous as its converse in Canada, the thinking apparently being that letting the government run the health insurance plan is tantamount to asking a five-year-old to change your car’s oil: it’s sure to be messy, expensive, frustrating, and somebody’s likely to get hurt.

Both the American and Canadian interpretations of health insurance reform can’t be correct. Where’s the truth in all of this?

It has been suggested for years that in reality neither of us is right, that some sort of ideal compromise existed. Eventually the United States and Canada would, after experimentation and study revealed an enlightened pathway, reach an effective, sensible equilibrium between private and public health insurance -- or so the theory went. This notion is known in comparative health policy studies as “convergence theory” and was especially popular in the early ’90s, when the Democrats were ascendant and Hillary Clinton was hard at work on drafting legislation to create a national health plan for the U.S.

We all remember what happened: the plan was destroyed by a combination of its own complexity, dissent within the Democratic Party, private-industry lobbying, and Republican scaremongering. The last fifteen years saw Canadian and American health policy remain as far apart as ever.

But, lo and behold, convergence theory was back again this year as the Democratic primaries saw the return of talk about universal healthcare and insurance mandates from Clinton and John Edwards. For a time it looked as though Canada was back in vogue in Washington. But University of North Carolina at Chapel Hill professor Jon Oberlander, the author of the 2003 book The Political Life of Medicare, recently warned me about the turn of events, “There might be more of a convergence in rhetoric than in reality.” Right he was. Barack Obama won the nomination and the party once again adopted a relatively centrist platform in the general election.

Canada’s single-payer approach is far from perfect, of course. Wait times are dangerously long in some cases, remuneration for physicians is lower than in the U.S., and medical technology lags behind. But for all its shortcomings, the overall cost of delivering healthcare is half in Canada what it is in the U.S. while health outcomes and mortality rates are essentially equivalent, and the discrepancy in healthcare quality between rich and poor is vastly reduced in the Canadian model.

Nevertheless, the prospect of following the Canadian example has lost what little currency the idea once had in the United States; a Canadian-style schema is as anathema to mainstream politics as ever. McCain’s plan would move the U.S. even further still away from Canada. And keeping in mind Obama’s modest tax plan has been blasted as Communist, just imagine what a call for universal healthcare would do to him; his campaign realized early on it was political suicide to propose anything like what exists north of the border.

“There are still a lot of people in the U.S. for whom ‘socialized medicine’ is still a dirty word,” Oberlander told me. “That’s why when John McCain calls Barack Obama’s plan ‘socialized medicine’ the campaign wants to shoot that down immediately. Those are fighting words here.”

Regardless of who wins on Tuesday, over at least the next four years Canadian healthcare will remain as foreign to Americans as ketchup chips or Bob and Doug McKenzie. Meanwhile, at the other end of the spectrum, Canadian forays into private health insurance have been few and far between, and severely limited in scope by existing laws.

In practice, convergence theory looks to have been a failure.


This essay was first published yesterday at KevinMD.

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2 comments:

  1. sharon3 November, 2008 2:19 PM

    Health Insurance:

    " piggy-back" it into mandatory policy ( home/auto) which has an early start with a long lifespan .

    Comparable sanctions in cost of policy will eliminate the dross.

    Delete
  2. sharon3 November, 2008 11:13 PM

    Insurance ( cont'd)

    Remember:

    if the insurance program " pays out " ....to the client..... upon receipt of "payment made" evidence
    ..... focussing on reimbursement...

    the following will happen:

    1.value-added
    i.e. you will have a tracking system in place that demonstrates the provider followed an appropriate costed careplan ( patient led)

    2. obstacle
    i.e.you will have patient obligation to "pay" before reimbursed

    3. incentive
    i.e. you will have "reduced use" because of the reimbursement methodology

    4. automatic creation of alternatives
    i.e.
    4.1 you will reinvent the " credit" economy who will create a "sliding rate scale"

    4.2 you enable the patient to be his own banker

    4.3 you restore purchasing power

    7. you honor competition law

    4.4 you will make those on guaranteed incomes ( pensioners) safe from harm as they become " preferred patients"

    Delete
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