They cite several reasons, including low public awareness, heavy workloads, fear that they won't be adequately paid and reluctance to treat drug-addicted people.

This article first appeared January 03, 2018 on Kaiser Health News.

By Anna Gorman

Gale Dunham, a pharmacist in Calistoga, Calif., knows the devastation the opioid epidemic has wrought, and she is glad the anti-overdose drug naloxone is becoming more accessible.

But so far, Dunham said, she has not taken advantage of a California law that allows pharmacists to dispense the medication to patients without a doctor’s prescription. She said she plans to take the training required at some point but has not yet seen much demand for the drug.

“I don’t think people who are heroin addicts or taking a lot of opioids think that they need it,” Dunham said. “Here, nobody comes and asks for it.”

In the three years since the California law took effect, pharmacists have been slow to dispense naloxone, which reverses the effects of an overdose. They cite several reasons, including low public awareness, heavy workloads, fear that they won’t be adequately paid and reluctance to treat drug-addicted people.

In 48 states and Washington, D.C., pharmacists have flexibility in supplying the drug without a prescription to patients, or to their friends or relatives, according to the National Alliance of State Pharmacy Associations. But as in California, pharmacists in many states, including Wisconsin and Kentucky, have divergent opinions about whether to dispense naloxone.

“The fact that we don’t have wider uptake … is a public health emergency in and of itself,” said Virginia Herold, executive officer of the California State Board of Pharmacy. She said both pharmacists and the public need to be better educated about the drug.

Pharmacists are uniquely positioned to identify those at risk and help save the lives of patients who overdose on opioids, said Talia Puzantian, a pharmacist and associate professor of clinical sciences at Keck Graduate Institute School of Pharmacy in Claremont, Calif.

“There’s a Starbucks on every corner. What else is on every corner? A pharmacy. So we are very accessible,” Puzantian told a group of pharmacy students recently as she trained them on providing naloxone to customers. “We are interfacing with patients who may be at risk. We can help reduce overdose deaths by expanding access to naloxone.”

Opioid overdoses killed 2,000 people in California and 15,000 nationwide in 2015.

Naloxone can be administered via nasal spray, injection or auto-injector. Prices for it vary widely, but insurers often cover it. The drug binds to opioid receptors, reversing the effect of opioids and helping someone who has overdosed to breathe again.

At least 26,500 overdoses were reversed from 1996 to 2014 because of naloxone administered by laypeople, according to the National Institute on Drug Abuse. Since then, the drug has become much more widely available among first responders, law enforcement officers and community groups. The drug is safe and doesn’t have serious side effects, apart from putting someone into immediate withdrawal, according to the institute.

Information on how many pharmacists are dispensing naloxone is limited, but one study last year showed access to the drug at retail pharmacies increased significantly from 2013 to 2015 from previously small numbers.

Interviews and available evidence from around the U.S. indicate that pharmacists have varying perspectives. In Kentucky, for example, one study found that 28 percent of pharmacists surveyed were not willing to dispense naloxone.

In Pennsylvania, pharmacists weren’t exactly lining up to hand out naloxone when the state passed a law in 2015 allowing them to do it, said Pat Epple, CEO of the Pennsylvania Pharmacists Association. She said there were some initial obstacles, including the cost of the drug and pharmacists’ limited awareness of the law. The association worked with state health officials to raise awareness of naloxone among patients and pharmacists and reduce the stigma of dispensing it, Epple said.

Wisconsin is also among the states that allow pharmacists to dispense naloxone. Sarah Sorum, a vice president at the Pharmacy Society of Wisconsin, said the state’s pharmacists want to expand their public health role and help curb the opioid epidemic. But reimbursement has been a challenge, she said.

Not all health plans across the nation cover the full cost of the drug, and pharmacists also are concerned about getting paid for the time it takes to counsel patients or their relatives.

California and other states require pharmacists to undergo training before they can dispense naloxone to patients who don’t have a doctor’s prescription. Puzantian and others say that in California not enough pharmacists are getting the training, which can be taken online or in person and can cost a few hundred dollars.

So far, the California State Board of Pharmacy has trained between 450 and 500 pharmacists, and the membership-based California Pharmacists Association has added an additional 170. Other smaller organizations offer the naloxone training, according to the association. There are about 28,000 licensed pharmacists in the state.

Once trained, California pharmacists who provide naloxone must screen patients to find out if they have a history of opioid use. They also must counsel people requesting the drug on how to prevent, recognize and respond to an overdose.

Some say training requirements are an unnecessary barrier, especially given the high level of education already required to become a pharmacist.

Some of the bigger pharmacy chains, including CVS, Rite Aid and Walgreens, have made the drug available without a prescription in the states that allow it. Walgreens has announced that it would stock the nasal spray version of naloxone at all of its pharmacies. It said it offers the drug in 45 states without requiring the patient to have a prescription.

Peter Lurie, president of the Center for Science in the Public Interest, said not every pharmacy has to dispense naloxone for people to have access to it. “But the greater the number of dispensing pharmacies the better,” he said, adding that it is “especially important in more sparsely populated areas.”

Corey Davis, deputy director of the Network for Public Health Law, said making naloxone available over the counter would also increase access, since people could buy it off the shelf without talking to a pharmacist.

Bryan Koschak, a community pharmacist at Shopko in Redding, Calif., said people should go to a hospital or doctor’s office for naloxone. “I am not champing at the bit to do it,” he said. “It is one more thing on my plate that I would have to do.”

Michael Creason, a pharmacist in San Diego expressed a different view. He did the training after his employer, CVS, required it. He said pharmacies are a great vehicle for expanding access to naloxone because patients often develop a rapport with their pharmacists and feel comfortable asking for it.

Pharmacy associations should educate their members about the laws that allow naloxone to be provided without a doctor’s prescription and persuade more of them to provide the drug to customers who need it, Lurie said. Others say more pharmacists should put up signs to make customers aware that naloxone is available in their shops.

The California Pharmacists Association said it is trying to raise awareness through newsletters and emails to pharmacists in the state. “We want to see every pharmacy be able to furnish naloxone and every person at risk have access to it,” said Jon Roth, the association’s CEO.

The state’s pharmacy schools also include the training in their curriculum. One day recently, Puzantian explained to a classroom full of pharmacy students that naloxone is effective, safe and can prevent death.

“You can’t get a dead addict into recovery,” she told the students. Drug users “might have multiple overdoses, but each overdose reversal is a chance for them to get into recovery.”

The deduction that allows people with very high medical costs to shrink their taxable income by subtracting some out-of-pocket medical expenses was a moving target during the congressional debate this fall.

This article first appeared December 22, 2017 on Kaiser Health News.

By Michelle Andrews

Patients scored a victory in the tough negotiations over the Republicans’ overhaul of the tax code.

The deduction that allows people with very high medical costs to shrink their taxable income by subtracting some out-of-pocket medical expenses was a moving target during the congressional debate this fall. Some lawmakers wanted to repeal it, but people with serious illnesses or who need long-term care said that eliminating the tax break would be a serious financial blow.

Congress has come around to their way of thinking, at least for now. The tax bill passed this month preserves and expands it.

Under the new law, people whose unreimbursed medical expenses exceed 7.5 percent of their adjusted gross income can claim a deduction for those expenses in 2017 and 2018. Then it is scheduled to revert to 10 percent for everyone, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities, a nonpartisan research institute in Washington, D.C.

That’s a lower threshold than current rules, which had required that people’s medical expenses exceed 10 percent of their income to take the deduction in 2017 if they’re younger than 65. For people 65 or older, the threshold already was set at 7.5 percent.

Yet even at the lower threshold, relatively few people can take the deduction because their medical expenses aren’t high enough, Straw said.

To start with, health insurance premiums for employer-sponsored coverage that many people pay for with pretax dollars generally don’t qualify, she said. “For many people, their premium is their biggest medical expense, and for most people, it can’t be deducted as a medical expense.”

In 2015, roughly 8.8 million taxpayers took the medical expense deduction, according to the Internal Revenue Service.

The House version of the tax reform bill eliminated the medical expense deduction, setting off alarm bells among consumer advocates for seniors and others. Lawmakers initially maintained that tax breaks such as the medical expense deduction weren’t necessary because their tax bill would provide so many other overall tax benefits to families.

The Senate version of the bill included the medical expense deduction and moved the threshold to 7.5 percent, at the behest of Sen. Susan Collins (R-Maine), who was concerned about high health care costs for seniors.

For the final bill, lawmakers settled on the Senate version.

By screening patients near the end of life, doctors often detect tumors that don't need to be found and treated.

This article first appeared December 20, 2017 on Kaiser Health News.

By Liz Szabo

Elena Altemus is 89 and has dementia. She often forgets her children’s names, and sometimes can’t recall whether she lives in Maryland or Italy.

Yet Elena, who entered a nursing home in November, was screened for breast cancer as recently as this summer. “If the screening is not too invasive, why not?” asked her daughter, Dorothy Altemus. “I want her to have the best quality of life possible.”

But a growing chorus of geriatricians, cancer specialists and health system analysts are coming forth with a host of reasons: Such testing in the nation’s oldest patients is highly unlikely to detect lethal disease, hugely expensive and more likely to harm than help since any follow-up testing and treatment is often invasive.

And yet such screening — some have labeled it “overdiagnosis” — is epidemic in the United States, the result of medical culture, aggressive awareness campaigns and financial incentives to doctors.

By looking for cancers in people who are unlikely to benefit, “we find something that wasn’t going to hurt the patient, and then we hurt the patient,” said Dr. Sei Lee, an associate professor of geriatrics at the University of California-San Francisco.

Nearly 1 in 5 women with severe cognitive impairment — including older patients like Elena Altemus — are still getting regular mammograms, according to the American Journal of Public Health — even though they’re not recommended for people with a limited life expectancy. And 55 percent of older men with a high risk of death over the next decade still get PSA tests for prostate cancer, according to a 2014 study in JAMA Internal Medicine.

Among people in their 70s and 80s, cancer screenings often detect slow-growing tumors that are unlikely to cause problems in patients’ lifetimes. These patients often die of something else — from dementia to heart disease or pneumonia — long before their cancers would ever have become a threat, said Dr. Deborah Korenstein, chief of general internal medicine at New York’s Memorial Sloan Kettering Cancer Center. Prostate cancers, in particular, are often harmless.

Patients with dementia, for example, rarely live longer than a few years.

“It generally takes about 10 years to see benefit from cancer screening, at least in terms of a mortality benefit,” Korenstein said.

Enthusiasm for cancer screenings runs high among patients and doctors, both of whom tend to overestimate the benefits but underappreciate the risks, medical research shows.

In some cases, women are being screened for tumors in organs they no longer have. In a study of women over 30, nearly two-thirds who had undergone a hysterectomy got at least one cervical cancer screening, including one-third who had been screened in the past year, according to a 2014 study in JAMA Internal Medicine.

Even some patients with terminal cancers continue to be screened for other malignancies.

Nine percent of women with advanced cancers — including tumors of the lung, colon or pancreas — received a mammogram and 6 percent received a cervical cancer screen, according to a 2010 study of Medicare recipients over age 65. Among men on Medicare with incurable cancer, 15 percent were screened for prostate cancer.

Although screenings can extend and improve lives for healthy, younger adults, they tend to inflict more harm than good in people who are old and frail, Korenstein said. Testing can lead to anxiety, invasive follow-up procedures and harsh treatments.

“In patients well into their 80s, with other chronic conditions, it’s highly unlikely that they will receive any benefit from screening, and more likely that the harms will outweigh the benefits,” said Dr. Cary Gross, a professor at the Yale School of Medicine.

By screening patients near the end of life, doctors often detect tumors that don’t need to be found and treated. Researchers estimate that up to two-thirds of prostate cancers are overdiagnosed, along with one-third of breast tumors.

“Overdiagnosis is serious,” Gross said. “It’s a tremendous harm that screening has imposed. … It’s something we’re only beginning to reckon with.”

A variety of medical specialties — from the American College of Surgeons to the Society of General Internal Medicine — have advised doctors against screening patients with limited time left. For example, the American Cancer Society recommends prostate and breast cancer screenings only in patients expected to live 10 years or more.

In November, a coalition of patient advocates, employers and others included prostate screenings in men over age 75 in its list of the top five “low-value” medical procedures. Dr. A. Mark Fendrick, co-director of the coalition, referred to the five procedures as “no-brainers,” arguing that health plans should consider refusing to pay for them.

Prostate cancer screening in men over 75 cost Medicare at least $145 million a year, according to a 2014 study in the journal Cancer. Mammograms in this age group cost the federal health plan for seniors more than $410 million a year, according to a 2013 study in JAMA Internal Medicine.

Taxpayers usually foot the bill for these tests, because most seniors are covered by Medicare.

And while cancer screenings generally aren’t expensive — a mammogram averages about $100 — they can launch a cascade of follow-up tests and treatments that add to the total cost of care.

Most spending on unnecessary medical care stems not from rare, big-ticket items, such as heart surgeries, but cheaper services that are performed much too often, according to an October study in Health Affairs.

A Hard Habit To Break

Many older patients expect to continue getting screened, said Dr. Mara Schonberg, an associate professor at Harvard Medical School and Boston’s Beth Israel Deaconess Medical Center.

“It’s jarring for someone who’s been told every year to get screened and then at age 75 you tell them to stop,” she said.

John Randall, 78, says he plans to live into his 90s. He sees no reason to skip cancer screening.

“I, for one, do not like to hear what my life expectancy is,” said Randall, who lives near Madison, Wis. He plans to have his next colonoscopy in January. He feels healthy and walks 2 miles at a stretch several days a week. “No one knows when I am going to die.”

Decades of public awareness campaigns have convinced patients that cancer screenings are essential, said Dr. Lisa Schwartz, a professor at the Dartmouth Institute for Health Policy and Clinical Practice. Her research found that many people see cancer screening as a moral obligation and can’t imagine a day when they would stop getting screened.

Such campaigns have convinced many women that “mammograms saves lives.”

But those campaigns don’t mention that doctors need to screen 1,000 women for a decade in order to prevent one death from breast cancer, said Schonberg.

Yet screenings can have dire consequences. Medical complications during colonoscopies — such as intestinal tears — are almost twice as common in patients ages 75 to 79 compared with those 70 to 74, according to a study published in January in Annals of Internal Medicine.

Colonoscopies, which require extensive bowel cleansing before the procedure, also can leave many older people dehydrated and prone to fainting.

PSA tests can lead to prostate biopsies — in which doctors use needles to sample tissue — that cause infections in about 6 percent of men. These infections send about 1 in 100 men who undergo the procedure to the hospital, according to a 2014 study in the Journal of Urology.

Even removing nonfatal skin cancers can cause problems for older patients, said Dr. Eleni Linos, an associate professor at the University of California-San Francisco School of Medicine. Frail patients can struggle to care for surgical wounds and change dressings; their wounds are also less likely to heal well, Linos said. More than 1 in 4 patients with nonfatal skin cancers report a complication of treatment, Linos’ research shows.

Yet most of the 2.5 million slowest-growing skin cancers found each year are diagnosed in people over 65, according to Linos’ 2014 study. More than 100,000 of these nonfatal skin cancers are treated in patients who die within one year.

Screenings, follow-up tests and treatments can cause emotional trauma as well.

“For a woman of that generation who doesn’t have the cognitive ability to understand what’s going on, having private parts of their body exposed and pressed against a machine can be very agitating and upsetting,” Lee said.

Among older women, about 70 percent report significant stress at the time of a biopsy, Schonberg said. Simply lying on a table for a 45-minute biopsy can cause pain for women with significant arthritis, she said.

Instead of spending time and effort on things that are hurtful and never going to help them, why not direct time and energy on things that will help them live longer and better?

Virtually all older women with breast cancer wind up getting surgery, which poses additional hardships, Schonberg said. Many are prescribed hormonal therapies that can cause bone pain, fatigue and increase the risk of stroke.

With prostate cancer, doctors today try to reduce the harm from overdiagnosis by offering men with early-stage disease “active surveillance” instead of immediate treatment. A study published last year in the New England Journal of Medicine found that men are just as likely to survive 10 years whether they choose to be treated or monitored.

Jay Schleifer, 74, of Wellington, Fla., was diagnosed with a low-risk prostate cancer last year. Since then, his doctor has monitored him with additional tests. He’ll be treated only if tests suggest his cancer has become more aggressive.

This less aggressive approach aims to spare Schleifer from long-term side effects.

Among men who have had prostate cancer surgery, 14 percent lose control of their bladders and 14 percent develop erectile dysfunction, according to a 2013 study in JAMA Internal Medicine.

In a study published in July in the Journal of Clinical Oncology, Dr. Richard Hoffman found 15 percent of prostate cancer survivors regretted their treatment decision. Those treated with surgery and radiation were about twice as likely to regret their choice compared with those who opted to monitor their disease.

Men are more likely to regret their prostate cancer treatment decisions if they don’t understand the risks beforehand, said Hoffman, director of general internal medicine at the University of Iowa Carver College of Medicine/Iowa City VA Medical Center.

Harold Honeyfield, 87, said he didn’t fully understand the risks when he had prostate cancer surgery 12 years ago. Although he is glad he was treated, the surgery caused irreversible erectile dysfunction, which has caused stress and sadness for him and his wife of 47 years.

“When a man has no erections, that is paralysis,” said Honeyfield, of Davis, Calif., who started a support group for other men dealing with prostate cancer. “You’ve lost the ability to be a man.”

A Tough Sell

Doctors have a number of incentives to continue ordering screening tests as people age.

“It’s a lot easier to say, ‘Fine, get your regular mammogram this year,’ than to have the much more difficult conversation that it’s not helpful when life expectancy is limited,” Gross said.

Schonberg said she tries to be diplomatic when talking to patients about halting screening.

In patients well into their 80s, with other chronic conditions, it’s highly unlikely that they will receive any benefit from screening.

“It’s hard to tell people, ‘You’re not going to live long enough to benefit,’” Schonberg said. “That doesn’t go over well.”

Many physicians continue screening older people because they’re afraid they’ll be sued if they miss a cancer, Schonberg said. And she notes that some health systems award bonuses to clinicians whose patients have high screening rates.

In addition, “doing less can be perceived as a lack of caring or as ageism,” Schonberg said. “It can be uncomfortable for a physician to explain why doing less is more.”

Doctors should prioritize what they can do to help patients be healthier, said Dr. Louise Walter, chief of geriatrics at the University of California-San Francisco and a geriatrician at the San Francisco VA Medical Center. For many older patients, screening for cancer is not their most pressing need.

“Instead of spending time and effort on things that are hurtful and never going to help them, why not direct time and energy on things that will help them live longer and better?” Walter asked.

For example, Walter might tell a patient, “‘Right now, you have really bad heart failure and we need to get that under control,’” Walter said.

Other key issues for many older people include preventing falls, treating depression and alleviating stress in their caregivers, Walter said. Gross said he urges patients to take steps shown to improve their health, such as getting a flu shot or exercising at least 15 minutes a day.

“These are things that can help them feel better very quickly,” Walter said. “Screenings can take years to have a benefit, if at all.”

American support for government-run, single-payer health care, once a fringe opinion, is picking up momentum.

This article first appeared December 18, 2017 on Kaiser Health News.

By Shefali Luthra

TORONTO — For Dr. Peter Cram, an American internist who spent most of his career practicing in Iowa City, Iowa, moving here about four years ago was almost a no-brainer.

He’s part of a small cohort of American doctors who, for personal or professional reasons, have moved north to practice in Canada’s single-payer system. Now when he sees patients, he doesn’t worry about whether they can afford treatment. He knows “everyone gets a basic level of care,” so he focuses less on their finances and more on actual medical needs.

Cram treats his move as a sort of life-size experiment. As a U.S.-trained physician and a health system researcher, he is now studying what he says is still a little-understood question: How do the United States and Canada — neighbors with vastly different health systems — compare in terms of actual results? Does one do a better job of keeping people healthy?

For all of the political talk, in many ways it is still an open question.

“The Canadian system is not perfect. Neither is the United States’,” Cram said over coffee in Toronto’s Kensington Market. “Anyone who gives you a sound bite and says this system should be adopted by this country … I think they’re being almost disingenuous.”

Still, American support for government-run, single-payer health care, once a fringe opinion, is picking up momentum.

Sen. Bernie Sanders, the Vermont independent who emphasized single-payer health care in his 2016 presidential bid, helped move Canada into the U.S. spotlight.

Lawmakers in California and New York have taken steps toward such programs on a statewide level, and the concept is a hot topic in gubernatorial campaigns in both Illinois and Maryland.

In addition, polling finds doctors and patients increasingly supportive, though the percentages in favor typically drop when questions are focused on the taxpayer costs of such a system.

In Canada, medical insurance comes through a publicly funded plan. And, while covering everyone, Canada still spends far less on health care than the United States does: just over 10 percent of its GDP, compared with the United States’ 16 percent.

To many American advocates, Canada’s health system sounds like the answer to the United States’ challenges.

But in Toronto, experts and doctors say the United States first must address a more fundamental difference. In Canada, health care is a right. Do American lawmakers agree?

“The U.S. needs to get on with the rest of the world and get an answer on that issue before it answers others,” said Dr.Robert Reid, a health quality researcher at the University of Toronto, who has practiced medicine in Seattle.

It’s an obvious disconnect, said Dr. Emily Queenan, a family doctor now practicing in rural Ontario. Queenan, 41, grew up in the United States and did her residency in Rochester, N.Y. By 2014, after about five years of frustrating battles with insurance companies over her patients’ coverage, she had enough. She found herself asking, why not Canada?

She moved north. Gone, she said, are the reams of insurance paperwork she faced in America. Her patients don’t worry about affording treatment.

“We have here a shared value that we all deserve access to health care,” said Queenan. “That’s something I never saw in the States.”

Sanders has pushed the discussion, with a “Medicare-for-All” bill in Congress and in a visit to Toronto this fall. It was part fact-finding mission and part publicity tour. On that trip, doctors, hospital leaders and patients painted a rosy picture where everyone gets top-notch care, with no worries about its cost to them.

“They have managed to provide health care to every man, woman and child without any out-of-pocket cost,” Sanders told reporters while speaking on the ground floor of Toronto General Hospital. “People come to a facility like this, which is one of the outstanding hospitals in Canada. They undergo a complicated heart surgery, and they leave without paying a nickel.”

It sounds idyllic. But the reality is more complicated.

While progressives tout the Canadian system for efficiently providing universal health care, the Commonwealth Fund, a nonprofit research group, puts it just two spots above the United States — which ranks last — in its health system assessment. It suggests that in timeliness, health outcomes and equitable access to care, Canada still has much to improve.

“If you deny there are trade-offs, I think you’re living in wonderland,” Cram said.

The Canadian Vibe

In Canada, everyone gets the same government-provided coverage. Provinces use federal guidelines to decide what’s covered, and there’s no cost sharing by patients.

“Come to our waiting room,” said Dr. Tara Kiran, a family doctor at St. Michael’s Hospital, in Toronto. “You will see people who are doctors or lawyers alongside people who are homeless or new immigrants. People with mental health issues or addiction issues together with people who don’t.”

But that insurance — which accounts for 70 percent of health spending in Canada —addresses only hospitals and doctors. Prescription medications, dentists, eye doctors and even some specialists aren’t covered. Most Canadians get additional private insurance to cover those.

In countries such as Britain or Germany people can opt out to buy private insurance. Canada prohibits private insurers from offering plans that compete with the government, a restriction some doctors are suing to lift. It’s not a popular view in Canada, experts said, but the implications are significant.

Here, the debate focuses more on bringing down health spending — a concern in the United States, too, but one often overtaken by politics.

Canada’s provinces put, on average, 38 percent of their budgets into health care, according to a 2016 report from the Canadian Institute for Health Information, a nonprofit organization. Canada’s single-payer system is supported by a combination of federal and provincial dollars, mostly raised through personal and corporate income taxes. (A few provinces charge premiums, which are income-based and collected with taxes.)

“We make improvements or change things only to have additional debates about other things. Those debates are constant, and they should be,” Reid said. “[But] most of what you hear in the U.S. is back to the tenor of the insurance framework, whether [they] should have Obamacare or not.”

Taxes in Canada are generally higher than in the United States. Canada, for instance, collects a levy on goods and services and also taxes wealthier citizens at a higher income tax rate.

But many here call that a concession worth making, and also note that they don’t have to pay separate premiums for health care as people in the United States do.

“We can’t have what we have if we don’t pay the taxes,” said Brigida Fortuna, a 50-year-old Toronto resident and professional dog groomer, while on her way to a medical appointment. “But you have to take care of your people. … If you don’t have good health care, you’re not going to have a good society.”

The Trade-Offs

That said, it’s not a perfect system. Canadian health care doesn’t cover prescriptions, physical therapy and psychotherapy. And there’s the concern that Canadians wait longer for health care than would Americans with robust health coverage.

There are cases, Reid said, when cancer care in Canada is delayed enough to yield health problems. Ex-pat Cram pointed to research that suggests low-income people are likely to wait longer for medical care — which can result in worse health outcomes.

“We do have a two-tiered system,” he said. “Most know it. Few will admit it.”

Typically, experts said, people with serious medical needs will jump to the front of the line for medical care. Kathleen Wynne, Ontario’s Liberal Party premier, said the Canadian government is actively trying to improve wait times.

But so far, it’s unclear how effective that’s been. A 2017 report from the nonprofit Canadian Institute for Health Information found that wait times had dropped for hip fracture repairs. But waits for, say, MRIs and cataract surgery have actually gotten worse. Depending on their province, the average wait for cataract removal ranged from 37 days to 148 days.

Many patients, though, said the waits were a trade-off they were willing to make. Toronto-based Nate Kreisworth, a 37-year-old music composer and producer, called it an obvious choice.

“You are not going to die because you’re waiting,” he said on a recent sunny morning while walking with his dog near Kensington Market. “Better wait times for everything? Sure, why not. But as long as the major issues are being covered, then I don’t think it’s really much of an issue.”

As Fortuna put it: “If you go for a headache and someone else is going to lose their arm, of course they’re going to take care of that person. I’m OK with that, because someday that could be me, too.”

Waits aren’t the only concern, though. There’s financing — and what it would cost for the United States to implement a system like Canada’s.

Because Americans have higher expectations about what a health plan should cover, it would be more expensive to adapt a Canadian approach, said Dr. Irfan Dhalla, an internist and health quality researcher in Toronto. And the quality may differ from what they are used to.

And in Canada, “everyone gets Kmart care,” Cram said. “There’s no Neiman Marcus care.”

Of course, some amenities that drive up costs — fancier food, softer gowns or private rooms — don’t necessarily produce better results.

A 2017 study found that patients with cystic fibrosis fared better in Canada than in the United States. But on the other hand, 2015 research comparing surgical outcomes found better results in the United States than in Canada. The Commonwealth Fund’s most recent ranking places Canadian health outcomes above America’s, but only by two slots.

Even so, many Canadians said they couldn’t imagine living with an American system. It’s a question not just of efficiency, but of fairness. Kreisworth compared his experience to that of family members in the United States.

“I talk to my brother’s girlfriend who is a part-time worker who has no [health] benefits — who would just be sick and not go to the doctor because she couldn’t afford to pay,” he said. “I can’t imagine that here. It seems like — it’s so wrong. It just seems utterly wrong.”