By Victoria Foe / The Rag Blog / August 5, 2009
I am a dual U.S./Canadian citizen. I am American by birth. I became a naturalized Canadian in my early forties and Canada was my primary residence for eight of my 63 years. Though I now live and work in the U.S., I still return yearly to Canada. I currently have medical insurance through my employer here in the U.S., and in the past, when self-employed, I purchased health care insurance as an individual.
I have first hand experience with Canada’s single-payer health care insurance program, to which I continue to subscribe. For-profit health insurance companies here are intentionally spreading misinformation about the Canadian system to frighten people away from a not-for-profit, government-administered insurance plan being added to the insurance options available to Americans. Here I correct five lies about Canada’s medical insurance program.
Lie #1. Canada has socialized medicine, putting the federal government, rather than doctors, in charge of medical decisions.
In fact the Canadian federal government plays only two roles: 1) it provides an eight page document — the Canada Health Act — outlining the attributes that Canadian medical insurance must meet (coverage of all “insured persons,” for all “medically necessary” hospital and physician services, without co-payments, transportable throughout Canada, and stipulates that the insurance program must be administered on a not-for-profit basis by the provinces) and 2) it transfers federal tax dollars to provinces whose medical insurance coverage meets these standards.
Except for complying with the Canadian Health Act, each province has autonomy in administering and delivering health care services and in determining how to finance its share of the cost of its health insurance plan. Financing can be through the payment of premiums (as is the case in Alberta and British Columbia), payroll taxes, sales taxes, other provincial or territorial revenues, or by a combination of methods.
In British Columbia I pay a premium of 640 Canadian dollars per year. In 2007 the total annual medical insurance cost, including provincial plus federal contributions, was $3,895 USD per Canadian, and everyone was covered; this contrasts with $7,290 per year in the US, while still leaving 44 million Americans uninsured (OECD Health Data, 2009; the World Health Organization data for 2006 shows a similar Canada/US health expenditure ratio).
Whereas the provinces manage the insurance component on a not-for-profit basis, and fund major facilities such as hospitals, healthcare itself is provided by physicians, most of whom are in private practice. Canadian doctors generally work on a fee-for-service basis, as in the U.S., but instead of sending the bills to one of hundreds of insurance companies, they send it to their provincial government.
Medical peer review (not the government) establishes best medical practice. Specifically, in each province a College of Physicians and Surgeons prescribes the diagnostic procedures and treatments shown to have the best outcome, provides advice on emerging diseases, preventative care etc.
Contrary to propaganda here, Canada’s version of national medical insurance is characterized by provincial control, physician autonomy and consumer choice. It is not the practice of medicine, but the business of insurance, that has been socialized in Canada, and the change from for-profit to non-profit insurance, plus low administrative overhead, has resulted in enormous cost savings in Canada.
In summary, Canadian medical insurance distributes risk over the entire population, is administered on a not-for-profit basis by the provinces, with oversight as regards fairness by the federal government, but with the actual medical services largely provided by private entities and with medical peer review prescribing best care practice.
Lie #2. Canadians have no choice of doctor and medical care is rationed.
In Canada the majority of physicians are in primary care practice. Canadians can go to any primary practice doctor who has an opening, in any Canadian province, whenever and wherever they need to.
It is true that before we can go to a specialist we need a referral from our primary care doctor, but many private insurance companies in the U.S. require the same. And here again, in Canada we can choose from among the relevant specialists, seek second opinions, and change doctors etc. The average number of physician visits per capita per year is about 6.0 in Canada, vs. 3.8 in the United States — hardly evidence of rationing and inverse to the yearly cost per person.
When in Canada this June I went to one of the three doctors who live and work on the island I used to live on, seeking a physician’s perspective on Canada’s medical insurance system. I asked how often the government had intervened in his practice. He was surprised by the question, and said “never.” He also claimed he has never been denied reimbursement for tests or treatments he prescribed, and his only complaint was that the wait time for diagnostic MRI is longer than he would like.
I asked what percentage of his time was spent on paperwork. He initially misunderstood my question to mean time spent documenting the medical needs and care of his patients in their charts. When I clarified my question to mean dealing with insurance coverage and payment, he snorted dismissively and said he did not spend any time at all on that, that billing was a small routine job his receptionist performed for him and for the two other doctors with whom he currently shares a clinic. I asked whether he felt cheated having to practice in Canada given that he could make more money in the U.S. He denied any envy and went on to opine that better medicine was practiced in Canada than in the U.S.
Lie #3. Public-funding of health insurance leads to second-rate medicine.
The proof of the pudding is in the eating thereof and World Health Organization analyses show that Canada consistently, and significantly, outperforms the United States in life expectancy, years of disability-free life, and infant mortality.
One might attribute this to the high number of uninsured Americans dragging down the national average. However, a systematic review comparing health outcomes in the United States and Canada among patients treated for similar underlying medical conditions (including cancer, coronary artery disease, and various chronic illnesses and surgical procedures) found that Canadian outcomes were more often superior to U.S. outcomes than the reverse.
Of course, there are outstanding and mediocre doctors everywhere, and of course, errors or malpractice by individual doctors can have tragic consequences anywhere. But there is no evidence that the 87% higher per-capita expenditures on health care in the United States systematically buys superior outcomes for the sick, or better preventative care.
Lie #4. Long wait times for medical care in Canada are routine.
In Canada, I have never needed to wait more than a day or two to see a primary care physician; in the U.S. I have never gotten to one that quickly. In Canadian cities, walk-in clinics supplement primary care doctors by attending to non-catastrophic urgent care that in the U.S. clogs emergency rooms. Life-threatening illness gets Priority 1 attention throughout the system.
Of course, Canadian doctors, like doctors everywhere, have preferences about where to live and raise their families. So, in the vast sparsely-populated country that is Canada, there are under-served communities, just as there are in the U.S.
The one common complaint I do hear from Canadians is that wait times are too long for diagnostic MRI and for those surgical procedures that the provincial Colleges of Physicians & Surgeons have designated non-urgent. Most complaints concern hip and knee replacements (in BC the median wait time for knee replacement is currently 13 weeks and 10 weeks for hip replacement).
Rather than add facilities that will be under-utilized, patients are queued, and patients needing emergency surgery and those in most urgent need of elective surgeries are moved to the head of the line. This practice annoys those waiting in line, but it has helped Canada hold per capita health care costs to just a little above 50% of what Americans pay for medical insurance, while still covering everyone, including for elective surgeries, long-term care and all hospitalization.
However, one consequence of having heath care administered by a government is that it becomes responsive to voter satisfaction. Reducing wait times is currently politically urgent in Canada, new funds have been targeted to increasing operating room capacity and MRI machines, and wait times are now shorter than a few years ago. (Wait list information by year is posted by each of the provincial Ministries of Health Services; e.g. www.health.gov.bc.ca/cpa/mediasite/waitlist/median.html).
One feature of Canadian health care that I think would amaze and delight Americans is the utter absence of paperwork for the user. When I go to my doctor, or for a test, or to a hospital I show my BC health card and that is the beginning and end of my part of the paperwork!
Lie #5. Given a choice, Canadians would choose the American system of medical insurance.
Access to good medical care as a universal right is a value that unifies the geographically vast and ethnically heterogenous country that is Canada, allowing citizens to move or change jobs while retaining health care coverage. Canadians are justifiably proud of their medical insurance program and value it so highly that Tommy Douglas (the colorful Baptist minister, premier of the prairie province of Saskatchewan and father of Canada’s universal health Insurance program) was voted “the greatest Canadian of all time” in a 2004 CBC poll.
Debates on how best to afford new medical technologies and the increasing medical cost of an aging population are ongoing north of the 48th parallel, just as they are here. But, as Saskatchewan physician E.W. Barootes, originally an opponent of universal health care, put it, “today a politician in Saskatchewan or in Canada is more likely to get away with canceling Christmas than… with canceling Canada’s health insurance program.”
President Obama’s Public Health Insurance Option vs. Universal Single-Payer Insurance.
Americans generally know little about the superior insurance programs other modern democracies give their citizens. And conservatives here have assiduously promoted distrust in, and disdain for, governmental programs. Thus, I think the Obama proposal of offering a not-for-profit government-administered insurance plan as an option, on a trial basis as it were, is a smart way forward. But, unless people rise up in huge numbers to support it, even that is going to be blocked by the for-profit insurance companies.
Friends, if good and affordable health care insurance is something that matters to you, we have August to make our opinions known, in every way we can. By the way, check out, add to, and pass along stories.barackobama.com/healthcare/.