Monday, August 13, 2012

An NHS Patriot

And now in honor of the close of the London Olympics, my tribute to the NHS...

"We're always trying to give the NHS as much publicity as possible in a positive light." -- Sarah Parish

I first became familiar with actress Sarah Parrish when I watched the miniseries Pillars of the Earth. Loved her performance as the evil Lady Hamleigh! More recently she gave an outstanding performance as Levicy Hatfield opposite Kevin Costner in the Emmy-nominated miniseries, Hatfields and McCoys. Sarah lives with her real life actor husband, James Murray, in Southampton, England. I met them in Vancouver last year where James was working on a TV series with my husband.

As a proud supporter of the National Health Service (NHS) in the UK, Sarah was enthusiastic about sharing her viewpoint on the British health care system with me. So we met up one day for tea and a chat about the NHS.

"Our first daughter was born with a severe congenital cardiac condition," Sarah began. "She would have died immediately had it not been for the outstanding care from the pediatric cardiology department at Southampton General Hospital." She continued, "The NHS had everything we needed."

"So, you don't have private health insurance?" I asked. "I don't want to buy into it," she responded. "You have to invest in the NHS for it to work-- That's the way I'm politically inclined," Sarah said firmly.

I took a sip of tea while I let that sink in.  "Do most high earners have private health care benefits?" I asked. Sarah thought they probably did. She attributed that to the tendency for people to believe if they pay more money they're going to receive superior care. But in her opinion, "You might get it quicker but you're not going to get any better care."

Sarah stated that you see the same doctors whether you have NHS coverage or private insurance. "The pride doctors take in working for the NHS is what makes it so special."

A little research on my part confirmed strong resistance on the part of British doctors' to the recently passed Health and Social Care law, which moves toward expanded privatization and disparities in care based on ability to pay. The British Medical Association, in fact, said that the relationship between family doctors and patients will suffer irreparable damage and that the reforms will be "irreversibly damaging to the NHS". Health care professionals have actually created a political party, the National Health Action Party, to fight the changes to the National Health Service. The voting was mainly along party lines with Labour voting against it and Conservatives and many Liberal Democrats voting for it. According to Sarah, right-wing and coalition governments are always a bum deal for the NHS, "Things get privatized, funds cut." 

Any experience with those waiting lists we hear about so much in the US? Sarah told me about her father's bout with colon cancer. Yes, he had to wait. In fact, his surgery was postponed at one point because someone with a more urgent condition took his place. From diagnosis to operation ended up being about two months. It caused the family some anxiety but everything ended up fine.

The system prioritizes the urgency of surgeries. Usually the system works. But of course, on occasion, Sarah said, "Mistakes are going to be made."

Getting back to health care cuts, Sarah and James have a particular concern about the threat to eliminate the pediatric cardiology departments in some of England's public hospitals. The program at the Southampton hospital where their daughter received such good treatment may be going under the knife. They have embarked on a public campaign to fight it.

Sarah said they like to be public about their use of the NHS, saying that when people learn that high profile actors are using the public system, "They figure if it's good enough for them [Sarah and James], it's good enough for us."

Outside the windows of the marina-side restaurant, a beautiful afternoon beaconed and we gathered our belongings to leave. "That's really quite something that you would forgo the convenience of the private system to support the NHS," I said admiringly. Sarah flashed me a confident smile and said, "You have to support your country."

Wednesday, February 15, 2012

The Doctor Down Under

I’m back to my blog after a few months hiatus. Since I wanted to continue my examination of the Australian health care system, I was thrilled that my Canadian pal, Rosie, was able to give me an email introduction to Dr. Sue O’Brien, a general practitioner in the health care clinic for Flinders University in Adelaide, Australia. Dr. O’Brien and I were able to chat via Skype about her experiences with the Australian health care system.

I was particularly interested in her perspectives as a physician in the Land Down Under. I decided to begin at the beginning with the cost for doctors to get their training. The tremendous student debt our young US physicians rack up is part of the case they make for being paid more here than in other countries. “Is it very expensive to train to be a physician in Australia?” I asked. “Well, at the time that I trained,” Sue responded, “it was completely free, plus I had a little bit of living support, which the federal government paid for.” Wow, can’t beat that with a stick!

But, as it turns out, the system is a bit different now. Still, most medical students who are Australian citizens only have to pay 1/3 of the tuition while the government pays the other 2/3. That averages about $9,000 per year for which the student is responsible. And a student at any income level can get a government loan for the full $9,000, which they don’t have to start paying back until they are earning a certain amount of money. If for some reason they never reach that threshold of earnings, they don’t have to repay the debt.

Do young Australian physicians still feel they finish school with an oppressive amount of debt? “They do feel that. They certainly do feel that,” was Dr. O’Brien’s reply. I guess starting one’s professional career already $36,000+ in debt is somewhat daunting but it can’t quite compare to the hundreds of thousands young US physicians owe.

My mind still on money, I asked Sue how she got paid. She told me that for her general practice patients, she does bulk billing. Bulk billing means that a doctor is willing to accept just the amount that Medicare covers. So the care is free for the patient. Australian docs are not obliged to bulk bill and can charge whatever they want. But even when Sue was in other practices, before she worked at the university, she accepted bulk billing. Consequently, she has seen many patients who were particularly needy.

In my previous post, “An American in Oz”, I wrote about how the Medicare Safety Net protects Australians from high non-hospital medical costs. When I asked Sue about the Safety Net, she mentioned there is also a Pharmaceutical Benefits Safety Net, which protects Australians from high medication costs. Even before Australians incurs high medication costs, they all qualify for the government Pharmaceutical Benefits Scheme. Under this plan, general patients can get most medications for $35 or less. When patients qualify for a concession because they: make less than $25,000 per year, are a student, are seeking work, are a pensioner – they can get generic prescriptions for $5.80. If a patient uses a brand name drug when a generic exists, the patient will have to pay more.

After a general patient has spent $1363 on medications in a year, the Pharmaceutical Benefits Safety Net kicks in and the rest of their medications cost $5.80. This benefit is not means-tested. If a patient is a Concession Card holder, their medications are free after they spend $348.

The Pharmaceutical Benefits Scheme covers only medications that are on the Schedule of Pharmaceutical Benefits. Dr. O’Brien informed me that most necessary medications are covered – most life saving drugs, medications for diabetes, hypertension, cardiac disease, infections, as well as medications for pain, anti-inflammatory agents, and oral contraceptives. Drugs that are not covered include some very new drugs, often for cancer, that haven’t been evaluated and approved by the government yet. “Are you ever unable to prescribe in a way that is in the best interest of your patients?” I enquired. “Hardly ever,” Dr. O’Brien stated emphatically. “Very rarely do I feel that a person needs a medication that they won’t be able to afford and there’s no alternative.”

Continuing this line of questioning regarding restrictions on what the government will cover, I asked whether in general she felt limitations on government health care coverage ever prevented her from giving her patients the best possible care. Her response was that Medicare doesn’t usually cover ancillary care – dieticians, physical therapists, podiatrists, dentists, psychologists – except for patients with serious chronic illnesses, for example diabetes, rheumatoid arthritis, or asthma. So occasionally Sue has patients who really need those services but because they don’t qualify for special chronic illness health support they aren’t able to afford it. However she added, “It’s quite unusual for me to feel that my patient really needs something that they won’t be able to get or that they will need something that they will not be able to afford.”

Sounds pretty good, doesn’t it?

Let’s look at some statistics that reflect the relative problem of affordability in Australia, Canada, and the US. According to a Commonwealth Foundation study, the percentage of people in these countries that had medical problems but didn’t visit a doctor due to cost concerns was 13% Australia, 4% Canada, and 22% US. Among below average earners, lower income US residents were about 2½ times more likely to have a serious problem or complete inability to pay medical bills than lower income Canadians or Aussies. Even above average US earners were twice as likely as above average Australian earners to have problems paying medical bills and about 5 times more likely to have difficulties than Canadians with above average income. So while some Australians have affordability issues, it’s a far less severe problem than in the US.

Going broke in Australia due to medical debt? “It would be rare,” said Sue. “Because hospital care, everybody’s covered for hospital care in the public sector. There are no costs for that.”

What about my favorite question: waiting lists? “Would you say that patients’ medical conditions deteriorate due to the waits?” I asked Dr. O’Brien. “I think that may happen sometimes,” she answered. “If somebody needs a hip replacement, there’s an optimal time to do it. And if the person has a lot of other medical problems, if they have chronic health problems like cardiovascular disease or diabetes, then because they have to wait, and they might have to wait for a year or something like that, then their other health conditions might deteriorate. And they may not be such a good operating risk.” But on the other hand, “What I find though, is that, and I’m sure other doctors would agree with this, if it’s a serious problem, let’s say it’s a dermatological problem and the person has a terrible rash, which is difficult to diagnose. Then you [the doctor] ring up somebody in the public system, you ring up the clinic, or the referral that you send, sends it as an urgent problem. And they’re very likely to be seen quickly.”

When I asked Sue whether there was anything that bothered her about the Australian health care system she asserted, “I think it’s quite a good system!” She went on, “If I try to think of ways in which it could be improved – There could perhaps be more direct funding of doctors who are willing to work in public hospitals. It used to be the case that there was more direct government funding for that. But the government has tried to get the private system to pay for more, a bigger proportion of the health service… More direct funding for doctors who are willing to work in the public system would presumably lessen the waits for people who can’t afford to get their health care in the private system. Because that’s probably the biggest problem. Waits in the public system.”

Australia’s national health care system, while not perfect, gives residents the option of health care that costs them nothing at the point of service. Medications are available to everyone at a relatively low cost. And although affordability is an issue for some, it is on a much lesser scale than in the US. There is also a private insurance industry that gives speedier access, more covered ancillary benefits, and upgraded hospital choices. Perhaps this is a model more palatable to Americans than systems that are more strictly egalitarian.

Wednesday, August 31, 2011

An American in Oz

It feels like only yesterday that I met Christine, my pal Jennifer’s little sister, while gathering signatures in Los Angeles on petitions for health care reform. She was still an undergraduate then. So seeing her via Google chat in her office in Adelaide where she practices psychology felt a little unreal. And the fact that she now has three children hardly seems possible. Christine, who has been living in Australia since 2006, was kind enough to take time out of her workday to talk to me about her experiences with the Australian health care system, as a patient, as a mother, and as a health care provider.

“How is mental health coverage in Australia?” I asked as we got the interview underway. I was surprised to learn that Medicare does cover some sessions with a psychologist. I had thought this was a service that was only covered by private insurance. Christine explained that a patient wanting to see a psychologist first goes to a GP to get a referral for a mental health plan. This means that Medicare will cover 6 sessions and then the patient has to go back to the GP to get a referral for 6 more sessions up to 18 sessions per year. Of course many Australians have private insurance that covers psychologists so they don’t have to depend on Medicare.

When I began asking about Christine’s experiences as a patient, she first explained a bit about her private insurance for which she pays $350 per month to cover herself, her husband, and her 3 children. I asked whether some people get private insurance as an employee benefit and the answer was no. Their insurance covers them for private hospital care and they also have ancillary coverage for things like dentists, physical therapists, and psychologists. At the level of coverage her family chose, they pay a $200 “excess”, which is like a deductible, each time they go to the hospital.

Christine has had 2 children while living in Australia. Because of her private insurance, “I got to go to a private hospital and I also got to have an obstetrician,” she told me. For women using the public system, they can either see a GP during the beginning of their pregnancy and then switch to a midwife or they can choose to just see a midwife for the entire pregnancy.

For the obstetrician, Christine paid $2,000 but then was reimbursed much of that amount because her total medical bills for the year went over the “Medicare Safety Net” threshold. The Medicare Safety Net protects Australians from high out-of-pocket costs for non-hospital medical expenses. There is also a Pharmaceutical Benefits Scheme Safety Net, which protects people from high medication costs. With the Medicare Safety Net, patients are reimbursed at one level after they have spent about $400 out-of-pocket and at a higher level after they have spent $1150 out-of-pocket. Now remember, Medicare typically covers most of the cost a doctor bill to begin with but the patient does have a copayment. Sometimes the out-of-pocket expense runs higher because the doctor charges more than the amount allowed by the Medicare Benefits Schedule.

I was very curious about how the system works with these reimbursements. For some people, I would think coming up with the money to pay a doctor could be difficult. So how long do you have to wait to get reimbursed? Christine told me it can be almost instantaneous. “The place where I work, we swipe their [credit/debit] card; they pay; then if they’re hooked up electronically with Medicare, we swipe Medicare’s card. Then we put their [credit/debit] card back in the machine and it puts the balance back into their account.” Nifty, huh?

The Australian system does have some annoyances for Christine. Yes, the waiting lists.

Christine considers it very fortunate that her father-in-law is a physician. He can often pull strings to get family members in to see a doctor more quickly. But not always.

Her daughter needed to see a gastroenterologist and she had to wait 1 ½ to 2 months in order to be seen. As a worried mother, “I felt it was more urgent,” Christine laughed. Then her daughter needed an endoscopy. But since that can be done in a private hospital, she was able to use her private insurance. Remember, private insurance is only for care provided in a hospital not for regular doctor appointments. Using the private insurance, Christine’s daughter got in for the endoscopy in one week rather than 3-4 weeks with the public system.

On another occasion, a check-up prior to starting school showed that her daughter was having some vision difficulties. It was going to take her 4-5 months to see a pediatric ophthalmologist but fortunately she got in slightly earlier due to a cancellation. “It wasn’t urgent by any means but I wanted her to get in before school started.”

Apparently, most folks who live in Australia aren’t so bothered by the waits. “I think I get more annoyed by things like that because I’m not used to it,” Christine observed. “But on the other hand, I do see that they feel very entitled to free health care. They get annoyed with having to pay anything. For me, I’m thinking, ‘Woo, all these things for free!’”

I finally asked Christine whether she would prefer getting health care from the U.S. system or the Australian system. Although she isn’t too fond of the waits, she said it had never caused her family a health complication. Her conclusion was, “I think I would rather be getting it through Australian system if for no other reason than you cannot be excluded from getting health care for a pre-existing medical condition, or forced to pay more for that reason.”

Thanks, Christine. Who knew all those years ago when we were gathering signatures for single payer health care in California, you’d end up living in a country with a national health care system – and 17 years later, we still wouldn’t have it in the U.S.?

Tuesday, August 16, 2011

The Aussies

Once again in my favorite spot for interviews, I engaged a smart-looking, 30something Australian couple in conversation while we waited to board our plane. Ms. Aussie had spent 3 years living in Vancouver and was familiar with both the Canadian and Australian health care system. “I loved the Canadian system!” she exclaimed enthusiastically.

In Australia, she told me, private health insurance plays a much larger role in the health care system. There is an Australian publicly funded universal health care system called Medicare, which covers everyone for medically necessary doctor’s services and hospitalization. Medicare is funded partly by a 1.5% income tax levy and partly out of general revenue. But 45% of Australians also carry private insurance – hospital coverage, ancillary coverage, or a combination of the two. Hospital coverage enables policyholders to go to private hospitals, choose their doctor when hospitalized, schedule elective surgeries more promptly, stay in a private room, and make up some of the difference between the amount the government payment schedule will cover for doctors’ charges whilst an in-patient and what the doctors actually charge (called the "gap"). Private "ancillary" insurance covers some of the extended services, like physical therapy, optical, and dental, the way the private extended coverage does in Canada.

In contrast with Canada, 1/3 of hospital beds are in private hospitals. According to Ms. Aussie, public hospitals are not so desirable. Private hospitals are more attractive cosmetically, have better food, and one can usually stay in a private room. Many public hospitals, on the other hand, are better equipped. Emergency rooms are almost exclusively found at public hospitals.

Interestingly, some folks who have private hospital coverage still opt to use a public hospital. They can choose to go to a public hospital either as a private insurance patient or a public patient. For patients not using private insurance, Medicare will pay for all the expenses incurred in the hospital. A private patient, even in a public hospital, will be scheduled for elective procedures with a shorter wait, will be able to choose their physician, and may be able to get a private room. For a private patient, Medicare will cover 75% of in-patient medical procedures in accordance with the Medicare Benefit Schedule (MBS). The private insurance picks up the remaining 25% plus the hospital accommodation costs. If the doctor charges more than the MBS fee, the private insurance may pick up the “gap”, depending on the policy.

Ms. Aussie's sister had used private insurance and a private hospital when she needed back surgery. She would have had to wait a year for the surgery had she used the public system, according to Ms. Aussie. Ouch! But she ended up paying $7,000 out-of-pocket due to the "gap" despite her private insurance. Oooouch!

The Australian government provides incentives for individuals to purchase private insurance; they believe it is better to relieve the government of as much of the business of health care coverage as possible. First of all, they provide a 30% subsidy to everyone who purchases private insurance and a higher subsidy for the elderly. Secondly, there is a 1% tax on the income of anyone earning more than $77,000 per year ($154,000 for couples) who doesn’t purchase private insurance. A bit similar to the US's impending individual mandate. And finally, if Australians don’t purchase private insurance by their 31st birthday, they pay an additional 2% to purchase insurance for every year beyond that time. So if you don’t start purchasing insurance until you’re 40, you pay an extra 20%. This protects the private insurers, who are not allowed to charge more for preexisting conditions, from having everyone wait until they are older and sicker to start purchasing insurance. Furthermore, private insurance isn’t terribly expensive in Australia. For Ms. and Mr. Aussie, this is a no brainer. Their income is over $154,000 so they’d be paying the government 1% of their income anyway. The private insurance they purchase only costs $90 per month for the two of them.

Ms. Aussie had no complaints about the care she had received in either country but she seemed to prefer the Canadian system. I guess more people end up paying more out-of-pocket for the Australian system. By the way, she mentioned, as have several of the Canadians I’ve spoken to, how important it is for them to purchase travel health insurance before coming to the US. Wouldn’t dare leave home without it!

Monday, August 1, 2011

What Does It Cost -- A Tale Of Two Sisters & Two Systems

One of my great pleasures during the time I spent in Vancouver was reconnecting with my cousin. Brainy, fascinating Cousin Catherine, who left the US after high school to go to Oxford. She never returned to live in the US, spending roughly 20 years in Great Britain and then the past 20 years in Canada.

One drizzly evening she invited me to dinner at her house. "Am I finally going to get to interview you about your health care?" I asked as we sat down at the dining room table in her cozy craftsman style home. "Well, yes, I suppose so," Catherine answered. We had had many conversations about the Canadian health care system, but we’d never gotten into details of her personal experiences.

"Have you had any problems with the Canadian health care system? -- Any waiting list problems?" No, she hadn't. No problems for her husband or kids.

The only complaint she could come up with was that family doctors generally are only willing to discuss one problem per appointment. Since sometimes multiple problems are interrelated, it can get a bit silly at times. "And I've also been coughing --" "Oh, you'll need to schedule another appointment." Even though you're not paying more for the additional appointment, who wants to spend day after day at the doctor's office?

In fact, Catherine is a huge fan of the Canadian health care system. When she goes back to visit family in the US, she often ends up in the exasperating situation of having Americans tell her how bad the Canadian system is. "People who haven't spent one day in Canada and clearly have no idea what they're talking about!"

Catherine is acutely aware of the difference between her health care situation and her sister's. Cousin Jean lives in California and is a booking agent for performing artists. She is in business for herself and therefore has to buy insurance on the individual market.

I decided to give Cousin Jean a call to find out the specifics. "I have no idea what I get," was Jean's first reaction. "I think something's covered and then they change it." Then she began to have second thoughts about talking to me about her insurance. "I'm trying to get new insurance. I don't want to jeopardize my chances." I told her I'd change her name.

In my years of working on health care reform in the US, I have come across lots of people who have these kinds of concerns about being blackballed by health insurance companies. It just goes to show how people fear the life and death control these companies have over their lives, as well as their ruthlessness -- like some sort of organized crime operation.

Once Jean was able to line up a new policy, she told me her premiums were now under $500 per month with a deductible of $6,000.

That's the price Jean pays for going into business for herself. Something her sister Catherine didn't have to worry about in British Columbia when she left her job at the university teaching Middle Eastern History, and opened a small publishing business. "I didn't feel tied to my job at the university because I knew my doctors and hospitalization were covered by the Medical Services Plan (MSP) here."

Monthly premiums for the MSP are $60.50 per month for one person or $109 per month to cover both Catherine and her husband. If their sons were still living at home, the premium would be $114 per month to cover all of them. These are the rates for anyone making over $30,000 per year. There are no deductibles, no co-payments, no guessing at what's covered. For those who make less than $22,000 per year, the premiums are $0 and for those making between $22,000 and $30,000 per year there is a sliding scale on premiums.

But what about those legendary high Canadian taxes, eh?

After doing some research online, for several income levels I added up federal taxes, British Columbian provincial taxes, the Canadian equivalent of Social Security taxes, plus the Canadian version of Unemployment Insurance (which comes out of the taxpayer's paycheck). Then I added up US federal taxes, California (where Jean lives) state taxes, Social Security, Medicare, and California State Disability Insurance. Much to my surprise, the tax rate on income at home is higher than on income in British Columbia. That was true at each income level I tested.

There are higher sales taxes in Canada, although some sales tax is refunded to low-income Canadians. Funding for health care comes out of a combination of Provincial and Federal taxes. There is no specific health care tax in British Columbia but that varies from province to province.

Is providing universal health care enormously expensive in Canada?

Well, let's compare it to the US. In Canada, they spent $4,079 per person on health care in 2008, whereas, in the US, we spent $7,538. In Canada they spent 10.7% of GDP on health care compared with 17.6% of GDP in the US. And of course, everyone is covered in Canada while 17% of Americans are uninsured and almost 20% of Californians are uninsured.

Yes, many Canadians think the amount their government spends on health care is unaffordable. I'm guessing that is the story in every country that has a modern health care system – the tale, as it were, of many cities.

Thursday, July 14, 2011

Waiting Line Reality Check

One of the issues that keeps bothering me is the problem of ending up on a waiting list in Canada with a painful but non-emergent problem. You know, those stories about long waits for joint replacements? Although, knock wood, I don't need surgery, I've gone through enough with my faulty parts to make me identify with patients in pain who don't want to wait for relief.

I was fortunate to be able to interview a Canadian physician whose specialty is roughly like an osteopath -- So he sees people for these painful conditions.

When I asked Dr. King about the problem of wait times, he assumed I meant wait times to get in to see him. In a similar fashion to the prioritizing in hospitals for surgical wait times, Dr. King tries to prioritize the cases that are most urgent. Patients who report being in severe pain can see him within a few days, but it can take a month or two for others.

If one of his patients may need a hip replacement (not a procedure he performs), he tries to anticipate their need for surgery. He'll encourage them to get on a surgeon's waiting list when he thinks a patient is likely to require a hip replacement in the future.

But what about when a patient is having a hard time functioning because of the pain? What kind of flexibility is there with the system? Is a hip replacement simply always low priority if it's not due to a fracture? No, according to Dr. King, it's possible to go to the front of the waiting line if a patient is in severe pain or can't function. Apparently, a specialist can successfully put the pressure on to help out a patient.

I took a look at the handy dandy wait time website for British Columbia: For hip replacement surgeries, when I checked the average waits for all of BC, I found 50% are done within about 3 months and 90% are done within about 7 months. There was considerable variation in wait times depending on the doctor a patient chose to see. The website showed some doctors were able to perform 90% of their patients’ hip replacements within a few weeks while other doctors showed 90% receiving the transplant within 14 months.

I also noticed variation in the time to receive some procedures depending on whether treatment was being sought in rural British Columbia or the Vancouver area. Wait times for back surgeries in one of the rural areas were running 90% done within 10-12 months and 50% done in less than 2 months. However, in the Vancouver area, 90% were done within about 4 months with 50% being completed within 3 weeks.

Another complaint one hears frequently is about the wait times for MRIs. Dr. King concurred. "The MRI is a real problem in this country." That is a medical service which can legally be purchased privately, if the patient can afford it. Dr. King said it costs $800-$1,000 to pay privately for a MRI in Vancouver. I spoke to a Vancouver neurologist, Dr. Cashman, who also expressed dismay over the wait for MRIs. When trying to diagnose ALS (Lou Gehrig's Disease), he wants to be able to get a patient in for a MRI right away. But the wait can be impossibly long. On the other hand, when the MRI is being ordered for a patient with a brain tumor, the service is provided promptly.

That being said, both Dr. King and Dr. Cashman like the Canadian health care system very much. In fact, they both came to Canada because they preferred the Canadian system to that of their native countries -- Great Britain and the United States respectively. Clearly, there are trade-offs to be considered with every health care system.

Thursday, July 7, 2011

Dr. Gabor Maté: Healing and Addiction

I knew going into this interview that in some ways, Dr. Gabor Maté viewed all Western medical systems as failures. In preparing for my conversation with Dr. Maté, I found other interviews with him online that clued me in to his perspectives on healing, ADHD, addiction, and chronic disease. And they didn't have to do with whether a government insurer or a private insurer provided benefits or whether a certain high tech procedure was covered.

I arrived at his house at the appointed hour and Dr. Maté invited me to sit down in his kitchen while he fixed some tea. A physician and best-selling author in Canada, I was honored he was taking the time to talk to me.

The major problem with the approach to healing in both Canada and the US, in Dr. Maté's view, is the insistence on separating the mind from the body when considering an individual's health status. He says that if we don't look at the relationship between stress and the immune system, many diseases will never be cured, no matter what the health care system. That doesn't mean Dr. Maté entirely negates the value of Western medicine. He explained that we need to "...get that the medical profession only knows what it knows. When it comes to chronic illness, they really don't know what to do."

Until recently, Dr. Maté was on the staff at the Portland Hotel Society, a Downtown Eastside Vancouver facility that provides housing and professional support for adults suffering from addiction, mental illness, and related problems, and at InSite, a supervised injection site affiliated with the PHS. He treated patients for drug addiction, HIV, and other health problems.

While both the Portland Hotel Society and InSite encourage addicts to seek detoxification and addiction treatment, they do not make abstinence a requirement for obtaining housing and services. They are principally harm reduction oriented. This approach is much more common in Europe, with the United States lagging behind both Europe and Canada. Studies documenting the success of the Portland Hotel Society and InSite have cited benefits including a reduction in the sharing of syringes and an increased use of detoxification services and addiction treatment.

As I steered my conversation with Dr. Maté back toward the subject of Canada's health care system he said, "I know I'm much freer to practice medicine the way I want to in Canada." He emphasized the need to spend as much time as it takes with addicts. This was made more feasible because the Medical Services Plan paid him for the amount of time he spent with his patients and not a set fee per service.

Dr. Maté informed me that the MSP covers all the doctors visits associated with the treatment of addiction. The coverage for residential rehab care is a different matter. Very low-income patients are covered through Social Services. People with private extended health insurance may be covered through their private plan. Some wealthy Canadians pay out-of-pocket for the very pricey Paradise Valley Wellness Centre and similar rehab facilities. Dr. Maté says that although it's a patchwork, "if somebody wants rehab, they'll be able to get in."

Dr. Maté is a fascinating and passionate healer. If you'd like to learn more and take a look at his books, check out his website: .