Tuesday, June 16, 2009

Canadian health care, part 2

In yesterday's post I said I was going to write about what the Canadian -- or, more specifically, British Columbian -- health care system was like for me as a diabetic person, but it turned out more to be a factual account of how the system works rather than a personal account. So today I'm going to write a more personal account.

When I'm sick, I go to the doctor. I don't have to ask my HMO if my particular doctor is "approved" by them. I don't have to ask if a particular doctor accepts the kind of insurance I have, because everyone in the province has the same insurance. I either call up my doctor's office and ask to make an appointment, or I go to the nearest walk-in clinic. I tend to use walk-in clinics a lot, actually, because I hate making telephone calls. Regardless, I go to the doctor when I'm sick. I don't sit around worrying about whether I can afford to go to the doctor; I just go. I don't have to pay anything. There is no deductible. There is no co-pay. No bill will show up in the mail.

Three times a year, I go to see my endocrinologist. I get a referral from my GP to go see my endocrinologist; specialists appointments are by referral. You can't just walk in to see a specialist. Specialists don't get paid if there is no referral. But I don't have to pay anything, not even for a specialist. I don't have to ask anyone's approval; I don't have to submit any kind of request to an insurance provider asking if they will "approve" my seeing this doctor. And no, the government doesn't "decide for me" if I can go see the endocrinologist.

My endocrinologist wants particular tests run. They include a hemoglobin A1C and a urinalysis. About a week before my appointment with the endocrinologist, I go to the lab, I give them my medical card, and they run the tests. My endocrinologist will have sent them a request for the tests. Again, I don't pay anything. I don't have to search to find out whether the lab closest to where I live accepts my particular brand of insurance, because as I said, everyone has the same insurance.

It's kind of like everyone in the province has the same HMO, except that for us, the HMO is the government. That's why it's called a "single payer" health system; everyone's health costs are paid for by the same provider, but for us, that provider is the government rather than a private medical insurance company.

Say I was in an accident, or my diabetes care got screwed up somehow and I ended up in DKA (diabetic ketoacidosis), and I had to go to the hospital. No one is going to make me fill out a whole bunch of forms if it's an emergency. No one is going to ask me how I'll be paying for my care. Eventually someone might ask for my MSP (medical services plan) card so that the hospital can bill the government for my care, but that won't be the priority.

Last year I went off disability benefits while I was going to school, and because I'd had a large windfall of money from an income tax refund, I lost my "medical only" income assistance (see yesterday's blog entry for an explanation of medical-only income assistance) and had to pay my own medical premiums. This wasn't a hardship, because I did have enough money. I was just unused to having to pay premiums, having been on either disability benefits or "medical only" assistance for the last ten years. I hadn't had to pay premiums in those ten years. So I forgot about it for awhile, and then I got a letter in the mail reminding me that I hadn't yet paid my premiums.

I had an endocrinologist appointment coming up, and I knew that my payment wouldn't be processed in time for that appointment, so I phoned up the medical services plan call centre and asked if I would still be able to go to that appointment and whether I'd have to pay for the lab tests I'd just had. "Oh, no, that's not a problem," I was assured. "Even if you don't pay your premiums, you still get health care. It's a necessity! We're not going to make you go without."

Monday, June 15, 2009

The Canadian health care system

There's been a lot of talk about the U.S. possibly implementing a "Canadian-style" health care system, and also a lot of misinformation about what a "Canadian-style" health care system actually is. So I thought I'd write a little about what it's like for me, as a Canadian with diabetes (as well as a few other chronic health conditions), under this system.

First of all, to be perfectly accurate, there is no "Canadian health care system." There are multiple systems -- one for each province and territory. I live in British Columbia, so I can really only talk about what the system is like here, though there are more similarities than there are differences between the different provincial system.

British Columbia is one of only a few provinces that charge health care premiums. These premiums are based on your yearly income. People with an income of less than $20,000 pay no premiums. The maximum premium, for people with an income of $28,000 a year or more, is $54 a month. Between those two amounts are various income levels with various levels of subsidy.

These premiums cover almost everything: doctor visits, hospitalization, lab tests, X-rays, etc. They do not cover prescription drugs. They do not cover psychotherapy. People with the highest premiums, the ones with an income over $28,000, do not get certain services covered, including physiotherapy, chiropractors or massage therapy. People who have lower premiums have these services covered, but do have to pay small "user fee" of about $10 to $15 per visit. People with higher incomes usually have these services paid for by their employers through various benefits packages.

Many of my American friends are surprised to find out that Canadian employers offer medical benefits, since the government does cover most of our health services. Benefits packages usually cover things that the government doesn't cover, like the aforementioned physio, chiropractors, and massage therapy, and prescription drugs. Some cover psychotherapy or offer "employee assistance" packages. Some pay the medical premiums for their employees.

For those who do not have employers who pay for their prescription drugs, we have what is called Pharmacare. Pharmacare is another sliding-scale plan that is based on a person's income. People whose income is less than $15,000 pay no deductible, but must pay 30 percent of their drug costs until they reach a maximum of 2 percent of their annual income spent on prescription drug costs. People whose net income is between $15,000 and $20,000 pay a deductible equivalent to 2 percent of their annual income, and then the government pays 70 percent of drug costs, until the person has spent 3 percent of their annual income on prescription drugs, at which time the government pays 100 percent of the drug costs. And people whose annual income is over $30,000 pay a deductible equivalent to 3 percent of their income, and then the second deductible is equivalent to 4 percent of annual income.

People who are on welfare or disability benefits have all their prescription drug costs covered by the government, and they don't have to pay medical premiums.

Because I am currently on disability, all of my diabetes supplies (and my other prescriptions) are covered by the government. If I go back to work, they will still be covered by the government under a program called "medical-only income assistance." This is a program that pays the costs of medication for people who have left disability assistance to go to work, but who would have trouble paying for their prescription drug costs if those costs were no longer covered by the government. The government sees this as a way to encourage people with disabilities to go to work and get off disability assistance.

What do I think of the British Columbia health care system? (As I said, there is no universal "Canadian" system.) I think it's not perfect, but I prefer it to the lack of a system in the United States. It has its flaws, certainly; the government has a tendency, in my opinion, to see health care as nothing but a big expense, and they tend to stigmatize certain diseases -- especially diabetes -- as being a "drain" on the health care system.

But I know too many Americans who have no health insurance. I know too many who are terrified of losing their jobs because if they do, they lose their health insurance. I have met people who say things like, "I think I'm having a miscarriage, but I can't go to the hospital because I have no money," or "I have diabetes, and I can't afford to pay for my insulin/syringes/test strips/etc."

There must be a better way.

Tuesday, June 2, 2009

Diabetes and hot weather

While it's not technically summer yet, my city has been experiencing some record-high temperatures over the last few days, and these temperatures are expected to last till the end of the week. When hot weather comes, there are some precautions I have to take when dealing with my diabetes.

One concern is dehydration. Dehydration is a concern for everyone, of course, but people who have diabetes have to be even more concerned. High blood sugar can cause dehydration, and some diabetes complications, such as certain forms of neuropathy, can impair the body's ability to sense dehydration symptoms. So I have to make sure I drink plenty of fluids on hot days.

I've discovered that the symptoms of low blood sugar seem to be pretty similar to the symptoms of heat exhaustion -- sleepiness, lightheadedness, confusion, etc. This causes me to check my blood sugar a lot more often when the weather is hot. Unfortunately, this means I use a lot more test strips than usual! Unfortunately, heat exhaustion is harder to treat than low blood sugar is. I'd rather have low blood sugar.

Heat also seems to lower blood sugar fairly quickly. I've noticed that I have to lower my insulin dosage on days when the temperature is abnormally high. There have been hot days when it seems like no matter what I eat, my blood sugar refuses to go above 4 mmol/l. While it's kind of nice to be able to eat anything I want, it's rather frustrating to have to be constantly treating myself for low blood sugar. I'm also sure it's not good for my weight to spend the day eating anything I want.

Then again, on hot days my appetite is diminished, so then I don't want to eat a lot. This means lowering my insulin dosage even more! Unless, of course, I decide to get a double-chocolate-chip frappucino from Starbucks. It's a lovely, chocolatey, cool drink, and Starbucks has lovely air conditioning, but it's going to wreak havoc on my blood sugar if I'm not careful and don't bolus appropriately for it.

And I'm probably not going to feel like exercising off the carbohydrates in that frappucino if the weather is hot. Exercise plus hot weather can equal dehydration and heat exhaustion, which brings us back to where I started this post.

So I will enjoy this hot weather while it lasts, but I'll also have to keep an eye on my diabetes while I do so.