Mental Health

How Does Your Local Health Care System Work?

How does your local health system work? Icons representing different aspects of health care

i was talking recently with Luftmentsch of Vision of the Night about the health care systems in. the UK and Canada, and I thought it would be interesting to take a look at what a patient scenario might look like in particular health care system.

Health care systems overview

First, let’s take a quick look at the basics of the health care systems in Canada, the US, and the UK. Being Canadian, that’s obviously what I’m most familiar with. I have some knowledge of the American and British systems, but I’m fairly clueless about the nuts and bolts everywhere else.

Canada

In Canada, medically necessary health care is publicly funded, and patients are not allowed to be charged for services. This is defined under a federal law, the Canada Health Act, but health care is administered by the individual provinces and territories. Federal transfers provide a large portion of the funding. My health coverage is tied to the province where I live, but if I need health care services in another part of the country, they’ll just bill my province.

Each province makes its own decisions about how to administer services. My province is divided up into a handful of health authorities, which run hospitals, public health services, and other assorted services. Physicians, and some other professionals in private practice, bill the government directly in a fee for service model. Private practice means they run their own office, but they still can’t direct bill patients unless it’s for a non-medically necessary service that’s not covered by the public system (such as Botox for cosmetic reasons).

UK

The National Health Service (NHS) is the public system in the UK. It seems… complicated, to say the least. There are local trusts, and there’s a lot of commissioning going on, although I can’t for the life of me figure out what that actually means. From what I’ve heard, I’m not convinced the NHS is entirely sure what any of it means either. The NHS England offers this video to explain how they’re organized, or perhaps just confuse you even further.

US

The U.S. has less of a system and more of a free-for-all. That’s free as in capitalist free-for-all, not health care that’s freely accessible. Some people have insurance coverage, some don’t. Even if you have coverage, that doesn’t mean you have access. You probably have to be concerned about what’s available in and out of network, as well as whatever co-pay you have to cough up.

About 30% of the population is covered by either Medicare (a federal program for seniors or people with disabilities) or Medicaid (a state-based program for people with low incomes). However, being covered doesn’t mean that providers will necessarily accept that coverage. In 2020, 1% of physicians overall have opted out of Medicare, but the specialty with the highest opt-out rate just happens to be psychiatry at 7.2% (Kaiser Family Foundation). According to a 2019 report (macpac.gov), only 35.7% of psychiatrists accept new Medicaid patients and 62.1% accept new Medicare patients. Compare the to 70.8% and 85.3% respectively as the overall average for physicians.

Throw in for-profit hospitals and the most expensive health care in the world, and you’ve got a not so pretty picture.

A patient scenario

The basic patient journey for this scenario is a patient whose GP has just started them on lithium and has referred them to a psychiatrist. So, let’s begin this journey if it were to happen in my province, British Columbia.

Seeing the GP

While some GPs here work at clinics operated by the local health authorities, most operate independently. For each patient visit, they bill the provincial health plan (here, it’s called the Medical Services Plan or MSP). Doctors don’t set their own billing rates; MSP has predetermined amounts associated with each billing code. If I’m a new patient at a GP’s office, I just need to show them my ID with my personal health number. GP visits are fully covered, so there’s no co-pay or whether or not they take my insurance or any of that American-style nonsense. Some things, like writing sick notes, aren’t billable under MSP, so some GP’s offices will charge for them.

So, I see my GP. He gives me a prescription to start the lithium, and a lab requisition to get a blood test a week later. He says he’ll send a referral to a psychiatrist.

Going to the pharmacy

Canada has been talking about starting a national pharmacare plan, but it hasn’t actually happened yet. While there would be an extra cost associated, having a single national payer would mean much better bargaining power with drug companies than provincial pharmacare plans can manage, so that would bring down drug costs. At least it’s better than the US, where getting screwed repeatedly in very uncomfortable positions by drug companies is apparently preferable to having the government get involved to slow down the money train.

As things currently stand, medications are fully covered for anyone while they’re in hospital, but in community, patients have to pay, and provinces may chip in means-tested coverage. Because my income was low last year, the province covered a portion of my meds all of this year, and last month I hit a deductible, at which point they were fully covered. Some people have “extended health insurance” through their employers that provides drug coverage.

Going to the lab

Basic laboratory services are covered by provincial health plans, but for the most part, they’re privately delivered. The lab closest to me is privately operated, but they bill MSP using my health number. I only have to pay if I’m requesting a particular test that’s not covered because it’s not medically necessary, like pharmacogenomic testing.

I grew up in a small town, and any time bloodwork was needed it was done at the hospital lab, because that was all there was in town.

Referral to a specialist

What happens at this step would depend on who/what I was getting referred to. A run of the mill psychiatrist would run their own show in private practice and bill MSP for each visit with me. The GP would refer directly to a psychiatrist that was taking new patients. If I needed to go to a specialty service or a mental health team that involved case managers and assorted others, I would be referred to the appropriate service operated by the local health authority. Those services are fully covered.

Therapy isn’t covered under the public health care system unless it’s part of a service delivered by the local health authority. If there wasn’t a health authority service that fit my needs in a timely manner, then I would have to pay to see a therapist in private practice. An extended health insurance plan might cover part of that cost.


So there you have it, an example patient journey in my part of Canada. Would things look different under your local health care system?

32 thoughts on “How Does Your Local Health Care System Work?”

  1. In US, two distinct insurance options provide very different service levels:

    HMO (health maintenance organization) is a health care plan in which you have to see your GP (called Primary Care Physician) for any service. They must refer you to a specialist before you can go. So if you know you have a skin condition your doctor won’t know shit about, too bad—you have to see them and get a referral or your dermatologist appointment won’t be covered. The GP may try to treat you to save money (the insurance company’s).

    PPO (preferred provider organization) lets you, the insured, see whomever the fuck you want without a gatekeeper.

    Can you guess which one costs more and gives you choices?

    Medicare charges us more for mental health care than for physical health care in our plan, which is through a private company in order to get more coverage. Medicare doesn’t cover a fucking tetanus booster. It is designed for old people even though disabled people are on it at any age. Medicare does not cover LMFT, the most common mental health credential in our region. Health care is ruled by special interest lobbyists (insurance companies, big pharma) in the US from what we can see.

    The people needed a lobbyist. Oh wait, it’s supposed to be the elected official lol

    1. I’ve been reading about how the supposed Mental Health Parity Act translates into pretty much diddly squat when it comes to implementation.

      Here, I would have to get a GP referral to see a specialist. Presumably that’s to avoid paying for a specialist for a problem a GP could deal with. But at least if everyone has to do it then people with less money are having to wait around while people with more money just waltz on in.

      It seems so messed up that the Pharma and insurance lobby has so much power. Obviously their priority is going to be profit, and it seems absurd for government to be giving them a free pass to fuck over as many people as they can.

      1. US system, PPO: Copayments are higher for specialists (say, $20 instead of $5) to discourage seeing one unnecessarily. Not a deterrent for the wealthy. The workaround is to see a nurse practitioner or other non-MD at the specialist’s office to get the lower copay but specialty expertise.

  2. I find it strange that psychiatrists in the US are less likely to accept people with insurance for low incomes and disabilities. These are the people who I imagine require mental health care the most.

      1. Top dollar psychiatrists who serve the wealthy in the U.S. are often little more than glorified drug dealers. When I worked for rich people in the Silicon Valley, it was a colloquialism to refer to one’s psychiatrist as a “dope dealer.”

        Even when I had Kaiser health insurance that I paid into, being self-employed, my psychiatrist in that part of the world didn’t take any time to understand or address my issues. We’d talk for a half hour about classical music (a mutual interest) and at the end of the half hour it was like: “Well, do you need a refill? How do you like the drugs?”

        One thing I appreciate about being poor and living in a much less affluent realm is that, while it may not be easy to come up with copays, the psychiatrists I have seen have at least listened to my issues and shown some genuine interest in whatever I may be about. Same with the M.D.’s for that matter.

        I’ve been revisiting a period of about 2 1/2 years ago lately, when I wrote frequently on this theme: https://edeninbabylon.com/2018/06/21/15599/ is a good example. For whatever it’s worth.

        1. I realize that was a little off-topic, but I was replying to a comment. I did enjoy the post, as usual. (I just need some sleep).

          1. That makes sense. Kinda like why someone would choose to work at a Denny’s restaurant, make minimum wage and walk out with fairly minimal tips, as opposed to a five-star ritzy restaurant, make minimum wage, and walk with tips in excess of $100 or more each night.

            I often wondered why that was the case, when I played piano at such a restaurant as is the latter. But maybe my analogy is obscure. I haven’t been sleeping at regular hours lately — stuff on my mind — and it’s been affecting my thought processes.

            Tempted to elaborate, but I’m only halfway through my “morning” cup of coffee. My ex-wife often commented that I tended to “babble” before sufficiently caffeinated.

            1. Before I commented on this comment, I commented on your comment on my 2018 post, but am commenting now in order to communicate that I have edited the previous comment, as I jumped out of bed to see what you had written and began typing before caffeine. 🙂

            2. I think for people who have the passion, it’s like playing at a dive bar where you can really connect with your audience vs. playing at swanky events where you could play the same set over and over in exactly the same way and no one would even notice.

            3. Actually I assumed you were referring to me, because I assumed I had already told you the story of how at Gulliver’s of San Francisco (a ritzy 300-seat five star restaurant with three dining floors and a full bar), I played the same set over and over again in the exact order every single night (while daydreaming) and I doubt anyone other than a few of the workers even noticed.

              I’ve also had the opposite experience of playing singer-songwriter stints at local coffeehouses and bringing down the house. Much more intimacy in that less monetary realm.

              By the way, I decided to go back to edit the comment on the 2018 post — which I thank you for not replying to yet — for a 3rd time. I wound up wiping out the lengthy precaffeinated ramble, and replaced it with a shorter, more cogent comment. I hope you will forgive my exposing you to my early morning neurosis. Have a good one —

            4. Lol it took me a while to realize that I probably had NOT told you that story, and that you were not referring directly to me.

  3. Wow, that’s a lot of info! I’m glad I don’t live in the UK. I’m not sure what they’re doing over there. Here, I have Medicare coverage for hospital admission and prescription drugs. That’s all that it covers. Nothing else. I could in theory buy an add-on insurance plan for roughly $120 a month (I think), but I don’t spend that much in medical bills each month to justify it. I pay Dr. Phlegm $130 per session, every six to eight weeks, and rarely need other medical care. And with that $120 plan, there would still be a copay of, like, $20 or $30. In case of minor emergency, there’s a Kroger Little Clinic right up the street, so I don’t worry too much and would find a way to pay them out of pocket. Like, well, one time I went there with a wrist injury (from ice skating), and they said, “We don’t have X-ray eyes, so you’ll have to go to the ER or self-treat it.” I wound up self-treating it to save a fortune, and my later research indicated that the particular injury is very hard to treat. You need a shot in the specific location, or the shot is ineffective. It took my wrist a year to heal (mostly I wore a wrist brace and iced it), and now I can’t give thumbs-up as high with that thumb. Otherwise fine. Anyway, I digress. I like having the Little Clinic up the street, and they’re really nice there. I don’t technically have a primary care physician. I had one–a nice one (I thought)–until I called for an appt, and the guy on the phone yelled at me for not seeing the doctor in over three years and fired me as a patient. Um. Epic fail of our system. Idiocy. Is it my fault for not having any physical health issues of note?

    So those are some of my experiences. American healthcare isn’t too bad. If you go to the hospital, they don’t worry about whether you can pay until after you’ve been treated, so it’s not a huge source of concern. Then you can apply for financial leniency with the bill if you’re broke. Unfortunately, you get hit with minor bills, like for X-rays or whatever, that you can’t cover with anything, and now I have one on my credit report. But, you know, life could be worse.

      1. Well, I could buy the add-on plan if I were to develop physical health issues. It would just cut greatly into my income. And the hospital coverage is a comfort. It apparently didn’t get accessed when I had pneumonia in 2016 because I wasn’t admitted beyond being in the ER. But when you add in that they’ll treat you regardless of your coverage, and that the hospital usually grants your appeal for reduced charges, it doesn’t leave me too anxious. But indeed, it would be great to have more coverage!! The Little Clinic doesn’t cost much. They didn’t charge me when I had the wrist injury, but if they had, it would’ve been $80 for the visit. Not too bad. And I made an eye doctor appt today, and it’s $150. Looking at those numbers, I think I’m saving money over having the add-on insurance plan and paying, like, $120 a month + a $30 copay to the doctor, etc.

  4. Thank you, Ashley: excellent post, and excellent points about the lack of health care in the US. Particularly around what Medicaid will not pay for (and Medicare as well), and how few providers actually accept either.

      1. Extremely unfortunate! And the kicker is that I just saw an article about a couple w/a husband from TN that moved up to Canada a few years ago, and the guy now raves about the health care system, asking why the US cannot have such a system: this a conservative from TN! If such a person, after living with a good health care system, can actually ask why we lack what less wealthy countries have (his words!), tell me: does it take every such person living in a country with a better system for them to understand? Why was this not obvious to the guy when he lived in TN and refused to go to the dr or hospital when ill or injured?

  5. Of my recent $35,000 hospital bill I paid nothing at all. Doctors and labs and tests were another story…but still our out of pocket expense for the year for the two of us will be $3-4 thousand dollars and we will have paid insurance premiums of close to $7000 for the 2 of us. Our monthly insurance premium will go up in January, as it does every year.

      1. It is…for the moment we can afford it. Lots of folks can’t and lots of folks don’t even have access to health care of any kind or at any cost. Welcome to the USA…

  6. As an American, your assessment of the U.S. is spot on. In the words of the late television anchor Walter Cronkite, “The American health care system is neither healthy, caring, nor a system.”

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