Who employs your doctor? Increasingly, a private equity firm

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.

You do need shelter, and those without housing should be provided somewhere to live. If you'd like to live somewhere nicer/bigger, then you can pay for that, but in a just society I don't see why there should be people starving on the streets. Economically, there are multiple studies that show providing housing to the homeless is at least net-neutral, and results in quite positive outcomes for participants [1,2,3]. Although the research is still in early stages and not deployed on a large scale, I think it at least illustrates the point that giving people who need it housing is not the straw-man that your comment implies it to be.

> My own healthcare is extremely valuable to me and I should be allowed to spend money on that. Someone else may decide they'd rather have a new pair of sneakers. Who am I to say they're wrong, that they are not permitted to allocate their capital in this way?

Sure, for some procedures, it may be viable to shop around or neglect them entirely. But for basic or emergency healthcare, there really isn't an open market. I don't think anyone would choose to "allocate their capital" to a new pair of sneakers when they're bleeding out in the street. For many people, even routine healthcare procedures are out of their financial reach, or at least or prohibitively expensive. Frankly, attempting to compare medical procedures to common goods is not really a fair comparison at all.

[1] https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201... [2] https://www.rand.org/pubs/research_reports/RR1694.html [3] http://isr.unm.edu/reports/2016/city-of-albuquerque-heading-...

I use Direct Primary Care.

I do not use doctors who are beholden to corporate bosses, insurance companies or shareholders.

COVID-19 has accelerated the parallel economy of Direct Primary (and Specialist) Care. It was a fork in the road, a bifurcation point, and many have decided which way they are going.

There are people who value medical freedom and the doctor-patient relationship, and there are some who value collective concerns "for the greater good" at the expense of individual liberty.