I've posted a variation of this in a number of other blogs, but what the hell, it's certainly fitting for this post:

A few weeks ago, I read The Day the World Came to Town, the story of the 250 flights that were diverted to and successfully absorbed by Gander, Newfoundland, on 9/11. Gander's population is around 10,000; it swelled by nearly 6,600 that day. Granted, the scale of the Katrina disaster was much greater, and no one had to be evacuated in Gander - but at the same time, NOLA had a few days' warning before the hurricane (compared to the few hours Gander had), and had far more resources at its hands than the little town in Newfoundland did.

Yet somehow, a pharmacist in Gander was able to stay up all night and phone doctors in several countries in order to fill prescriptions for passengers who were stranded without their luggage. (Among other truly uplifting feats: the one that amused me the most is that when the school bus drivers, who were on strike, heard that hundreds of passengers would have to be driven to neighbouring towns, they laid down their picket signs and started working overtime for no pay.)

That-all said, the stranded 9/11 passengers got their prescription drugs with minimum delay in Canada, which has a much more centralized health care system than the US. In all likelihood, a random uninsured American visitor who suddenly fell in in Canada would have more than a bit of trouble obtaining prescription drugs. Centralization isn't the problem; the problem is an institution that isn't able to cut through red tape even during emergencies.

Er, make that "a random uninsured American visitor who suddenly fell ill in Canada". Though I suspect that a random uninsured American visitor who suddenly fell in in Canada would encounter similar difficulty. Should avail myself of that "preview" function more often.

Oh hell, I'm not faulting you one lousy typo in an otherwise excellent comment. Please. If you posted something of the kind on your blog I'd happily link it and pimp it. You could have all three of my readers!

Centralization isn't the problem; the problem is an institution that isn't able to cut through red tape even during emergencies.

I think where I was going with the anti-centralization argument is that in any large country, centralization has the effect of adding layers to the onion, layers of red tape in this case. The national director can't possibly handle all the minutiae at the smallest local level, so you wind up with regional directors who then hire state directors who then hire--you increase the complexity. Not always, but often.

But your example is an excellent counterpoint. Centralization does not necessarily cause red tape, but it can certainly correlate with it.

If you posted something of the kind on your blog I'd happily link it and pimp it.

Heh, thanks, but I promised myself long ago that I'd never discuss American politics in any form on my blog. Partly because I get stressed enough just reading about them on other blogs, and partly because I just don't have the temperament to research someone else's country to the extent necessary to write intelligently on the subject. I've read commentary about Canadian politics by Americans who didn't bother to research Canada to the extent necessary to write intelligently on the subject, and I wouldn't want to inflict that sort of thing on anyone.

But, this comment here is All About Me, Sort Of, and I can write about that, so. Regarding centralization and its correlation with red tape - in some cases, absolutely. But Canada's health care system is a strange beast, and in many ways I think that centralization has made it more efficient. I can walk into any doctor's office in BC, for instance, hand them the health card that I obtained lo these many years ago in Ontario, and get placed in line to see a doctor right away. The fact that there's a single system in which all Canadians' health data is stored makes this process more efficient, rather than less. By contrast, I work at a US-based summer camp, and on occasion have had to accompany campers to hospitals. Half the time, much cross-checking of insurance info occurs before my camper gets the go-ahead to see a doctor. In one particularly upsetting case, a Colorado resident who had a goddamned CONCUSSION was sent to the waiting room for an hour while the receptionist at the Maine hospital phoned around and made sure that her insurance was legit. (I had a handful of twenties in my wallet, and at one point I asked a nurse if I could just pay upfront if that would get my poor camper processed immediately.)

My point is not to idealize Canadian health care (I'm well aware of its limitations: one of my grandmothers once went to NYC for cancer treatment that wasn't available in Canada, and my other grandfather was almost killed when a negligent doctor (or pharmacist?) accidentally tripled the dose of his blood-thinning medication (!!)), but there are certain flavours of bureaucracy that are almost entirely absent from Canada's system, but that are at least allowed to occur in the US's. And I have to give a decently-managed sort of centralization partial credit for that.

Partly because I get stressed enough just reading about them on other blogs

I have those days myself. But I'd bet the farm your average Canadian citizen has a better understanding of U.S. politics than the average U.S. citizen has of Canadian ones. Heaven knows I don't know dick about Canadian politics.

Half the time, much cross-checking of insurance info occurs before my camper gets the go-ahead to see a doctor.

Yes, yes, YES. I've been applying for medical secretary/receptionist positions recently, and it's listed as a required skill--"insurance verification." It wastes hours. The paperwork is horrendous. Despite fax, despite email, it remains a monumental communications hassle.

When I worked for a county healthcare clinic, I found that patient registration went fairly smoothly for patients already entered in the state's Medicaid system--their coverage, at least, was in a mainframe database I could pull up quickly. Of course, many of them would have three separate entries from clerks who were too lazy to inquire if "Rosa C. Gonzales," "Rosa C. Gonzalez," and "Rosa Gonzales" were, you know, the same person. But at least it was a matter of a few keystrokes to get them started being seen. Versus dealing with private insurance, which . . . arrrrrrggh. I've blocked most of those memories out. Hopefully, the patients have too.

Regarding centralization and its correlation with red tape - in some cases, absolutely.

And here I was gonna be all tactful and not bring that up. That was TRAGIC.

The fact that there's a single system in which all Canadians' health data is stored makes this process more efficient, rather than less.

The problem here is people'd pitch a fit over that. "You mean . . . you mean . . . ANYONE can access my information?" Buddy, anyone can access your information NOW. It just takes a little longer, is all.

And here I was gonna be all tactful and not bring that up. That was TRAGIC.

Fortunately, it's all going smoothly now, but for awhile, dealing with the EI folks looked like it was going to be the worst-paying job I'd ever held in my life. And, good call, 'cause if you'd brought up that experience as proof positive that centralization is always bad and should be avoided at all costs, then, yeah, I'd've lit into you for sure.

(And I'm not even sure that centralization is to blame for the EI kerfuffle, anyway; I and my commenters had plenty of stories about encounters with bureaucracy in the private sector. I'm sure that EI would be run a lot more smoothly if, say, the data were not stored on computers from the EIGHTIES, and no I am not making that up.)

The problem here is people'd pitch a fit over that. "You mean . . . you mean . . . ANYONE can access my information?"

Then you'll looove this little nugget of irony: Canadians (BCers in particular) are awfully worried these days about their health information being accessible to anyone. But we're not worried because it's stored all in one place in Canada. We're worried because it's stored in multiple random places. In America.

I just realized that I appear to be contradicting myself with the "everyone's health data is stored in one place, no it's not" in comments #3 and #7. Lemme clarify that: the provinces have their own systems, which they can run as they wish (with various degrees of privatization, some more controversial than others), but each province recognizes health cards from every other one. I've never had trouble using my Ontario card in BC. (I think Quebec might be an exception to this.) Public health care existed in the provinces several years before it existed on a national level, hence the structure. Not that I'm even slightly an expert on the matter.

Wouldn't want to put an end to the double-posting trend here, see.

But I'd bet the farm your average Canadian citizen has a better understanding of U.S. politics than the average U.S. citizen has of Canadian ones.

Heh, not if my relatives are part of the sample! Yes, I have relative issues :)

The national director can't possibly handle all the minutiae at the smallest local level, so you wind up with regional directors who then hire state directors who then hire--you increase the complexity.

I was pondering, as I fell asleep last night, something similar. If my house catches on fire, and the Monterey fire department screws up, I'm not going to blame the Governor for it. So I think odd things when I'm sleepy :)