[stubybubs]

I live in Canada, where we have socialized medicine. Our survival rates for major cancers are on par the US and our infant mortality rate is lower, though we spend far less. We certainly have problems related to physician pay and cost of living crisis, but we are dealing with them. A lot of the problems we have here are the same as in the US: not enough nurses due to burnout, retiring physicians, etc.

I have never once in my life thought "I sure wish there was somebody in the middle extracting value from this whole situation." Contributes absolutely nothing. Doctors are plenty efficient (pathologically so) and no MBA is going to speed things up. Long term outcomes are ideologically opposed to short-term capitalism. You cannot relate a reduction in type 2 diabetes or stroke cases 20 years later to a quarterly report. It's insanity to have them involved at all.

[chimeracoder]

> I live in Canada, where we have socialized medicine. Our survival rates for major cancers are on par the US

That's not really true. Cancer is one area that has been extensively studied over multiple rounds of years-long comparative studies, and while Canada is not as far behind the US in survival rates for cancers as other developed countries are, it's still decisively behind the US.

You're correct that the middlemen here serve no purpose and are effectively leeches upon the system (with patients paying the price in the end, with both their wallets and their health). However, cancer is not the example that proves this point - it's one are where the US system does quite well, by the numbers.

[stubybubs]

For breast cancer, we're talking 88.6% vs 85.8%. It's very much on par. We generally do better with lower socioeconomic status people as well. Another thing to consider is that we treat everyone. You don't have to consider of it's going to bankrupt your family before you engage in treatment. So we often treat people who are sicker and poorer because we don't have affluence as a selection mechanism for our patient population.

[chimeracoder]

> For breast cancer, we're talking 88.6% vs 85.8%.

Sure, you can cherry-pick one family of cancers to make a point, but again: there's a whole series of studies that have been conducted on this exact question for the last 30+ years, tracking all common cancers, and which have consistently shown the same results: while Canada does not perform as badly (with respect to the US) on cancer survival rates as many other OECD countries do, Canada does still fall behind the US.

> Another thing to consider is that we treat everyone. You don't have to consider of it's going to bankrupt your family before you engage in treatment. So we often treat people who are sicker and poorer because we don't have affluence as a selection mechanism for our patient population.

Yes, and that actually works against your point: even though there people in the US who can't get treated because of cost barriers, the survival rates are still better in the US.

There are a lot of things to criticize about the US healthcare system. The survival rates of cancers are not one of them.

[stubybubs]

https://wisevoter.com/country-rankings/cancer-survival-rates...

It's not cherry picking, I just didn't add a whole chart. It's on par, considering our different populations, climate (most of the country is frozen for half the year), and the extent of our coverage. I'm not saying it's worse, it's as on par as you can get given the variation in such a thing.

The uninsured don't count towards cancer rates if they don't receive a diagnosis. If you're uninsured and losing weight, anemic, night sweats, and your doctor says it could be serious so you walk away because you won't be able to afford it, you don't count as a cancer diagnosis. Assuming you went to the doctor at all. That does no count against my point.

[chimeracoder]

> It's not cherry picking, I just didn't add a whole chart.

It is cherry-picking. As I said, there are multiple, decades-long peer-reviewed studies on this topic (which is not what you linked). Raw numbers don't mean a whole lot for comparative studies, because confounding variables such as basic demographic differences will always swamp whatever effects you're trying to observe. Peer reviewed studies measure and account for these; a news site reporting raw statistics does not.

> climate (most of the country is frozen for half the year)

I have no idea how you're concluding that this affects survival rates for cancer.

> The uninsured don't count towards cancer rates if they don't receive a diagnosis. If you're uninsured and losing weight, anemic, night sweats, and your doctor says it could be serious so you walk away because you won't be able to afford it, you don't count as a cancer diagnosis. Assuming you went to the doctor at all. That does no count against my point.

Late diagnoses mean inferior care, and higher mortality rates. It's very rare for people to die of cancer that is neither diagnosed nor detected at any point, including upon death. This isn't speculative; it's a topic that is extensively studied in public health. Again, this is addressed in the studies conducted by professionals tasked with answering this exact question about cancer survival rates.

It can be tempting to start from a prior ("the US healthcare system is less affordable than Canada's systems") and then find explanations that fit that prior ("people don't get diagnosed with cancer because they can't afford it"), or search for data which supports that prior. Unfortunately, that's a logical fallacy, and it often leads to conclusions that are contradicted by the hard evidence at hand - which is what researchers have found.

On that note, you may be surprised to learn that healthcare in Canada is not, in fact, universal. An estimated half a million people in Canada do not have access to healthcare. That's actually slightly higher than the uninsured rate for the elderly in the US (which is the cohort for which the overwhelming majority of cancer diagnoses occur).

[stubybubs]

Okay, I assumed some kind of charitable interpretation, but that isn't happening.

There are plenty of criticisms of studies like CONCORD. Survival rates lacking context are not the end-all of comparison studies. A significant portion of this is around diagnosed and undiagnosed, which is a really critical distinction when you're talking about survival rates.

If you have no coverage or you are worried about cost, you are less likely to present and ever be diagnosed with cancer. Silent deaths are a real thing. People will die rather than burden their families. There is no cost to being diagnosed in Canada and other countries with some kind of socialized medicine, so people tend to just get diagnosed. So already your starting sample is different.

Who does get diagnosed, and at what stage, also skews the results. If you have gold-tier coverage and you live in a place where billing for tests is incentivized through profit, you get a sample of very early stage cancers with a very high cure rate, or more importantly for your stats, you get a better 5-year survival rate, which is the what the survival studies measure. This is due to "starting the timer" when you find microscopic evidence of cancer, so you are in effect pumping your stats, because of course people are more likely to survive for more than 5 years if you find the cancer earlier. What happens after 5 years is called mortality and is a statistic of its own that diverges from survival. This is well known:

https://pubmed.ncbi.nlm.nih.gov/10865276/

The last line says it all.

But catching cancer earlier is surely a good idea, isn't it? The problem is that morbidity is also part of this picture. Cervical cancer screening (the pap smear) is a great test that catches a lot of precancerous and early stage cancer cells. So many, in fact, that it's actually too good. Because we ended up doing LEEP on a bunch of cancers or precancerous cervixes that in fact would have just gone away on their own, and we left a bunch of women with "incompetent cervix" who are more prone to pregnancy loss for the first year. Big deal, the first year? The thing about being a doctor is that your patients are humans, and it really fucking sucks to have one of your patients go through losing a pregnancy, and sometimes, especially with patients in the 30-40 age range who are more likely to have abnormal cells, every year counts in terms of their remaining fertility. So you can't just shrug this off as unimportant. We changed recommendations around screening in part due to the efficacy of the HPV vaccine, and in large part because we overtreated. Much of those cancers simply go away on their own, with far less morbidity than if we treat every single one. Are we going to make the same mistake with HrHPV? Oh, probably. It takes time to find the sweet spot between effective diagnosis and overtreating.

Colorectal cancer is in a similar boat. Great cure rates and prevention with precancerous polyp removal for your healthiest and wealthiest. Every stage 1 that you get counts towards your 5-year survival rate. Unfortunately all this screening also result in a lot of surgery to remove non-malignant polyps, and that surgery has a mortality rate near 1% with significant morbidity. These people did not have cancer, but might have at some point in the future. Or they might not have! Because only about 5% of adenomas progress, and even if they do progress, you might be dead before you really feel like you have cancer. So again it's pumping stats without necessarily improving outcomes.

Beyond that, we do have different populations, partly because of latitude, which is what I meant by "frozen half the year":

https://i.imgur.com/DNwkkAj.png

Vitamin D via sun exposure seems pretty strongly correlated with lower rates of colorectal cancer. We simply do not get the same amount of UV rays at this latitude. We are also an MS hotspot, possibly for the same reason. Both conditions can be more frequent and potentially worse because of this.

Our populations are different, our testing is different, our access is different due to our geography. In spite of all this, our survival rates are comparable to the extent that you can compare them, and a difference of 2-3% is really not that great, especially given the different in testing.

As for half a million not having access, you will have to give some details on that. Yes, that geography problem exists, and it can be bad especially for first nations and other remote communities, but this is different than not being able to go do a doctor because you have not paid, which is not a thing that happens here.

This is all just with cancer. Consider also as I said in the original post, our infant mortality is lower. Consider also that our life expectancy is about 4 years longer. All this, for not just slightly less money than the US, but less than half what the US spends per capita on healthcare. We are currently expanding it to dental, and medications are on the list as well.

Personally having practiced in the system in Canada, there are things I love about it, and things I would change. We do not fight with insurers here, that is not a thing. Never. We don't have to preauth with any company before we order a test, nor do we get paid extra for additional tests. We order them when they are needed, if they are needed. Nobody's going bankrupt up here from hospital bills. More private imaging would be great, for CTs and MRIs, still paid by the public system with private capital paying the startup cost.

But if you prefer a system that gets 2-3% on a gamed stat, be my guest.