A Canadian doctor diagnoses U.S. healthcare
The caricature of 'socialized medicine' is used by corporate interests
to confuse Americans and maintain their bottom lines instead of
By Michael M. Rachlis
UNIVERSAL HEALTH insurance is on the American policy agenda for the
fifth time since World War II. In the 1960s, the U.S. chose public
coverage for only the elderly and the very poor, while Canada opted
for a universal program for hospitals and physicians' services. As a
policy analyst, I know there are lessons to be learned from studying
the effect of different approaches in similar jurisdictions. But, as a
Canadian with lots of American friends and relatives, I am saddened
that Americans seem incapable of learning them.
Our countries are joined at the hip. We peacefully share a continent,
a British heritage of representative government and now ownership of
GM. And, until 50 years ago, we had similar health systems, healthcare
costs and vital statistics.
The U.S.' and Canada's different health insurance decisions make up
the world's largest health policy experiment. And the results?
On coverage, all Canadians have insurance for hospital and physician
services. There are no deductibles or co-pays. Most provinces also
provide coverage for programs for home care, long-term care,
pharmaceuticals and durable medical equipment, although there are
On the U.S. side, 46 million people have no insurance, millions are
underinsured and healthcare bills bankrupt more than 1 million
Americans every year.
Lesson No. 1: A single-payer system would eliminate most U.S. coverage problems.
On costs, Canada spends 10% of its economy on healthcare; the U.S.
spends 16%. The extra 6% of GDP amounts to more than $800 billion per
year. The spending gap between the two nations is almost entirely
because of higher overhead. Canadians don't need thousands of
actuaries to set premiums or thousands of lawyers to deny care. Even
the U.S. Medicare program has 80% to 90% lower administrative costs
than private Medicare Advantage policies. And providers and suppliers
can't charge as much when they have to deal with a single payer.
Lessons No. 2 and 3: Single-payer systems reduce duplicative
administrative costs and can negotiate lower prices.
Because most of the difference in spending is for non-patient care,
Canadians actually get more of most services. We see the doctor more
often and take more drugs. We even have more lung transplant surgery.
We do get less heart surgery, but not so much less that we are any
more likely to die of heart attacks. And we now live nearly three
years longer, and our infant mortality is 20% lower.
Lesson No. 4: Single-payer plans can deliver the goods because their
funding goes to services, not overhead.
The Canadian system does have its problems, and these also provide
important lessons. Notwithstanding a few well-publicized and
misleading cases, Canadians needing urgent care get immediate
treatment. But we do wait too long for much elective care, including
appointments with family doctors and specialists and selected surgical
procedures. We also do a poor job managing chronic disease.
However, according to the New York-based Commonwealth Fund, both the
American and the Canadian systems fare badly in these areas. In fact,
an April U.S. Government Accountability Office report noted that U.S.
emergency room wait times have increased, and patients who should be
seen immediately are now waiting an average of 28 minutes. The GAO has
also raised concerns about two- to four-month waiting times for
On closer examination, most of these problems have little to do with
public insurance or even overall resources. Despite the delays, the
GAO said there is enough mammogram capacity.
These problems are largely caused by our shared politico-cultural
barriers to quality of care. In 19th century North America, doctors
waged a campaign against quacks and snake-oil salesmen and attained a
legislative monopoly on medical practice. In return, they promised to
set and enforce standards of practice. By and large, it didn't happen.
And perverse incentives like fee-for-service make things even worse.
Using techniques like those championed by the Boston-based Institute
for Healthcare Improvement, providers can eliminate most delays. In
Hamilton, Ontario, 17 psychiatrists have linked up with 100 family
doctors and 80 social workers to offer some of the world's best access
to mental health services. And in Toronto, simple process improvements
mean you can now get your hip assessed in one week and get a new one,
if you need it, within a month.
Lesson No. 5: Canadian healthcare delivery problems have nothing to do
with our single-payer system and can be fixed by re-engineering for
U.S. health policy would be miles ahead if policymakers could learn
these lessons. But they seem less interested in Canada's, or any other
nation's, experience than ever. Why?
American democracy runs on money. Pharmaceutical and insurance
companies have the fuel. Analysts see hundreds of billions of premiums
wasted on overhead that could fund care for the uninsured. But
industry executives and shareholders see bonuses and dividends.
Compounding the confusion is traditional American ignorance of what
happens north of the border, which makes it easy to mislead people.
Boilerplate anti-government rhetoric does the same. The U.S. media,
legislators and even presidents have claimed that our "socialized"
system doesn't let us choose our own doctors. In fact, Canadians have
free choice of physicians. It's Americans these days who are
restricted to "in-plan" doctors.
Unfortunately, many Americans won't get to hear the straight goods
because vested interests are promoting a caricature of the Canadian
Michael M. Rachlis is a physician, health policy analyst and author in Toronto.