Yes
Yes
Yes
Im stepping away from this conversation, which is way off thread.
Is there still private practice in Canada for those who want it? i.e. single payer but not single provider?
It is illegal in Canada for a private entity to provide medical services that are covered by single-pay Medicare. That is, there is no private competition permitted for the services that are mandated to be covered by Medicare.
Private providers do exist but are only allowed to provide these “non-covered services”. There are significant exceptions to this though. In British Columbia, the public Workers’ Compensation body and the public Automobile Accidents insurer both are permitted to contract with private providers for any services to their benefit recipients. I believe private insurers also enjoy this flexibility.
I think over 30%+ of Canadian medical care spending is still in the private sector.
I wonder how big a patient base is necessary for a hospital to be economically stable in the US. A lot of the recent closures are in rural(ish) areas.
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Hard to understate how big a deal this is. I’ve a buddy who’s a billionaire. My BIL lives at or below the poverty line. They have identical access to medical services in Canada. Which is the same access that the prime minister receives, and the homeless guy on the streets.
Its been around long enough that this ideal is pretty much cultural at this point. I think most Canadians would be offended by the idea that someone who’s wealthy would get better treatement, and they’d likely also be offended by the idea that a homeless person doesn’t have access to medical care.
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Would the billionaire ever fly to the US for better treatment if, (heaven forbid or however you want to put it) they would need something serious like a transplant?
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I dunno transplant but yes, they had a family member with some really out there medical issues and they went outside of Canada for treatment. But that’s pretty rare.
You would definitely use $$$ to skip the queue if you needed access to specalist care.
Canada works for basic medical care. But once you get to “specialist care” you will have to wait your turn, which is precisely why people with money in Canada head to the US.
Have quite a few friends from school in the Canadian healthcare space (Providers, Drs, and management consultants).
Looking at various websites, a rural hospital has a ~0.4% chance of failing each year. (They count closures and converted closures, but converted closures simply mean the hospital is no longer inpatient, but has not gone out of business). An established business (been in business for 15 years) has a >4% chance per year. That’s more than 10x the chance. So it doesn’t seem hospitals fare any worse than other types of organizations, and perhaps they fare quite a bit better.
And one of the reasons given for the failure (the first one when they go into detail) is simply lack of demand, and especially, lack of commercial patients. Another reason is that they can’t afford the high cost of labor (aka, can’t pay doctors and nurses as much as their wealthy urban counterparts).
Summary
https://www.aha.org/system/files/media/file/2022/09/rural-hospital-closures-threaten-access-report.pdf
Fast Facts on U.S. Hospitals, 2025 | AHA
Percentage of Businesses That Fail | LendingTree
What Percentage of Businesses Fail? [2025].
I think this underscores hospitals being a utility with the additional issue that many of their employees are used to a high rate of compensation. Increasing the supply of doctors should probably help, however this is done. Treating hospitals as semi-monopolistic structures (to be supported in areas of low demand, to be regulated in areas of high demand) should assist as well.
That might not be the best comparison, although I 'd struggle to find a better one. I imagine hospitals are on the larger side of businesses when it comes to revenue.
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Yeah that’s why I wasn’t definitive with my conclusion (" So it doesn’t seem hospitals fare any worse than other types of organizations, and perhaps they fare quite a bit better") but it seems like at least they don’t do any worse. And those are just the rural ones.
Anyway, my point about hospitals is less about the tiny rural ones (yeah, any business has problems when it doesn’t have enough potential customers, though it seems the tiny rural ones aren’t doing that badly anyway) and more about the medium and large ones, which I think are a big part of the reason our health care system is so messed up. The medium and large ones have captive customers and have been doing whatever they like for a while now, whether it’s pay themselves high salaries while being nonprofit, whether it’s charge exorbitant amounts while refusing to state prices in advance in any serious way (all the while having big posters saying you can ask for charges in advance - hahahahahaha), and the like.
Hospitals in the US are interesting. Rural hospitals in states that didn’t expand Medicaid are often struggling, while facilities with a large base of wealthy-ish commercially insured beneficiaries can be quite profitable. They can get some added revenue for treating uninsured and under-insured patients, things like DSH payments and 340b drug pricing.
However, in some cases those are driving some perverse activity. Facilities have been actively recruiting physicians who work in a physician office setting. Say you’re a rheumatologist who owns a small office-based practice. If you were to join a hospital, then you could get higher reimbursement rates for office visits (mostly due to facility fees), and you would have a much larger drug margin on your Enbrel and Remicade and what-not due to 340b pricing. Win-win for the physician, who is treating the same patients with the same drugs and making more on both ends. But this site-of-service cost differential adds cost to the system. Article below, if you google it you’ll find numerous studies.
As @tty points out, hospitals are a utility, we need them. We need to work towards keeping the lights on in some rural hospitals, and ensuring that other hospitals aren’t using their market leverage to squeeze out exorbitant sums of money.
https://www.healthaffairs.org/content/forefront/does-site-care-change-cost-care
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Yes. It is not like some other industries where you let market forces prevail to let the weak die. Accessibility of adequate health care facilities should be a right (says the Canadian socialist).
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not quite as universally held in the US it seems
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Tiny rural hospitals typically have plenty of “customers”. What they often lack is doctors willing to work there and customers who can afford to pay.
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I don’t envy the Health actuaries here. P&C can get a little political (e.g. California) but Health just seems so intertwined with it.
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I worked in health for about a minute, and never major medical, but the thought of investing in a career in that field never made me feel good.
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That seems to be the strange thing about our health care system. In some cases, the control of physician training seems to have been so extensive that we have a shortage of doctors, and an MD is maybe the only remaining license to be wealthy,
But on the other hand, i don’t think you can say that rural primary care physicians are doing overly well.
And some hospitals are very rich. Certainly the “non profit” status is a tax indicator that doesn’t say much about how much money they actually make. But the overall picture seems much more complicated.
I’m on the provider side, and have been for a while. To a pretty decent extent we live and die by policy and policy changes. But so far, the trend has been increasing complexity so the actuarial job market has gotten larger. Analytics in general has been pretty hot in healthcare for the last decade plus I’d say.
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