All citizens are covered and costs are lower, but patients have to wait
By Jim Landers / The Dallas Morning News
EDMONTON, Alberta (The Dallas Morning News), November 5, 2007:
Linda Littlechild, 56, had quadruple bypass heart surgery last month. Had she been living in Texas instead of Canada, she might still be struggling for breath, hoping to make it to 65 and Medicare.
Or worse.
"In the States, I'd a probably been dead. I couldn't afford an operation like this," she said recently from her hospital bed at the University of Alberta Hospital.
On the other hand, Mrs. Littlechild – if she had health insurance – would have gone into a U.S. operating room soon after tests showed the blockages in her heart's arteries. In Edmonton, she waited three months.
Dr. Brian Day, president of the Canadian Medical Association, argues that access to a waiting list is not access to health care. "Canadian patients are suffering and dying on waiting lists, yet we are one of the richest countries in the world," said the Vancouver orthopedic surgeon.
These are the two faces of the Canadian health system: All 33 million Canadians, regardless of income, get hospital and doctor care as a civic right. But the health program leaves patients waiting – sometimes more than a year – for surgeries, diagnostic tests and appointments with specialists.
Chelsey McLaughlan and son Sawyer visit the University of Alberta hospital. Photo: Candace Elliott/Specialist ContributorOne in seven Americans lacks health insurance and faces falling into a medical and financial abyss if they become seriously ill. That is not a worry in Canada.
Though rare, some Canadians have faced deadly consequences while waiting for medical care. That is usually not a worry for insured Americans.
Canada's wait times and America's uninsured drag both nations down in international surveys measuring the performance of health care systems.
A survey released in May by the New York-based Commonwealth Fund comparing six countries ranked the United States sixth and Canada fifth. (Britain and Germany came in first and second, with Australia and New Zealand tied for third.)
Still, Canadians live longer, have lower rates of infant mortality and suffer fewer preventable deaths than Americans. Canada has fewer doctors and MRI machines, but more nurses and hospital beds.
Another big difference between the systems: the cost. The United States spends far more per person on health care ($7,498 a year) than does Canada ($4,548), according to the latest numbers available from both governments.
Most of Canada's health care system is paid for through taxes. The U.S. system relies on private insurance split between employers and employees, with the government getting involved for the poor and the aged.
Nearly one third of what Americans pay for health care goes to administrative costs. Such costs in Canada are a third of what's the amount spent in the United States, according to a 2003 study by Harvard Medical School.
Some Americans point to Canada as a model of humane treatment, while others describe it as an ominous example of socialized medicine.
Critics of Canada's approach say the waiting is a way to ration health care to hold down costs; defenders say waiting was a problem of the 1990s, when government budgets were starved by a weak economy.
Today the most egregious wait times are being shortened, while the rest involve triage, with the most critical cases served first. Each province in Canada has its own health care delivery system and wait times, but it can take one or two months to get an MRI exam in Canada and a year to get a knee replacement.
"We monitor our wait list," explained Dr. David Johnstone, clinical director of a new hospital under construction in Edmonton that will be called the Mazankowski Alberta Heart Institute. "There will always be deaths on the wait list. Our target is to be sure there are no preventable deaths."
Many Canadian physicians and hospital administrators have worked or trained in the United States, where they marvel at the advanced technology and research but shudder over the plight of the uninsured.
"I have family in Houston. I've walked past the blocks of elite hospitals for heart patients, cancer research, and I've thought, 'This would be so wonderful to work here,' " said Michele Lahey, chief operating officer of Capital Health, the nonprofit medical care provider for Edmonton and northern Alberta. "But then I think, ethically, why would I want to? We don't accept that health care is a market issue, and in the U.S., you do."
Michael Moore's film Sicko lauds the Canadian approach as humane, which polls suggest is how most Canadians see it themselves.
Sandra Reid, a 55-year-old Vancouver deli owner, recently came out of a showing of Sicko angered by Mr. Moore's reports of insured Americans denied treatment.
"It's shameful. The common person is unimportant in the United States," she said. "I'd never want to live there. The only persons who can live there and have a good life are the ultra-rich."
Her husband, 46-year-old Tom Paterson, tried to be more upbeat: "Hopefully in the future, things will improve in your country."
Dr. Robert Woollard, head of the department of family practice at the University of British Columbia, belongs to a group of physicians that defend Canada's health care system. Their motto is: "Accessible health care is the highest expression of Canadians caring for one another."
"There's also a very practical attachment to it," Dr. Woollard said. "You're not going to go broke because you got sick, and that's a pretty profound thing."
Mrs. Littlechild, the bypass patient, said she considers herself fortunate to have gotten the surgery. And she has no complaints about the Canadian taxes that go for health care.
She works in an office stacking boxes, while her husband is a building caretaker – jobs that often do not come with insurance in America. Together they make about $29,000 a year, she said.
Many Americans at the age and income level of the Littlechilds find themselves not poor enough for Medicaid, too young for Medicare and challenged by the cost of health insurance, which averages $1,009 a month for a family of four.
Mrs. Littlechild's surgery and hospital care in Canada "hasn't cost a cent, from beginning to end," she said.
And she adds that she does not feel her wait was excessive.
The average wait for a bypass operation like hers in the Capital Health region is 12 weeks – twice what the Canadian government set last year as an acceptable target. Dr. Johnstone said the Alberta Heart Institute will cut wait times substantially when it opens next year.
In Canada, the federal and provincial governments pay 70 percent of health care costs. This covers hospital and physician care. The money comes from income, corporate and sales taxes, as well as natural resource royalties. The remaining 30 percent comes from employer-provided supplemental insurance and out-of-pocket payments for pharmaceuticals and other care.
Canada monitors drug prices and sometimes orders pharmaceutical firms to cut those considered excessive – a system that has resulted in cheaper drugs and lured many U.S. buyers across the border. For years, Congress has debated whether to allow Americans to legally import Canadian drugs, but drug makers have successfully argued that would be an imposition of U.S. price controls.
Canadians pay more taxes than Americans – 32 percent of the gross domestic product, against 26 percent in the United States. Canadian companies, meanwhile, pay far less in health insurance premiums than their U.S. counterparts; that is one reason it's cheaper to build a car in Canada than in Michigan.
Health care (including pharmaceutical costs) consumes 15.2 percent of the U.S. gross domestic product, but only 9.2 percent of the Canadian economy, according to estimates compiled by the Organization for Economic Cooperation and Development in Paris. Those estimates include all health care spending – whether funded by taxes, insurance premiums or out-of-pocket payments.
The federal government transfers money to Canada's 10 provinces to administer health care and sets minimum standards for the provincial plans. Alberta, wealthy in oil and natural gas, adds more of its own money for health care than other provinces.
Provinces and professional associations negotiate physician fees. Regional health authorities administer hospitals, medical schools and public health programs.
Some provinces charge residents a separate health care premium to help cover the costs. Alberta's is $44 a month for individuals and $88 a month for families. Alberta employers typically pay most of this premium for employees.
Pharmaceuticals, dental work, physical therapy and psychiatric care are funded separately through private insurance plans bought by patients or their employers, as well as by direct payments by patients.
While Americans talk of moving toward government-supplied coverage, some in Canada advocate introducing more American-style care.
Dr. Day, who runs the private Cambie Surgery Center in Vancouver, wants Canada to allow private medical insurance and private clinics so patients can get treatment more quickly.
Some Canadian provinces ban private insurance for hospital and physician care because it would upset the equal access aspect of Canadian health care.
Private surgeries and clinics exist in a gray area of the law. Government workers' compensation boards, loath to pay for time away from the job because of injuries, have sent workers to clinics like Cambie Surgery to get them back on their feet without waiting in line.
In 2005, the Canadian Supreme Court ruled that Quebec had to allow patients alternative ways to receive health care if they were forced to wait for so long that they were effectively denied treatment. Quebec has since allowed private health insurance for hospital and doctor care – the only province so far that has done so.
Dr. Woollard opposes this approach, saying it would let physicians practicing in public hospitals offer patients quicker, more expensive service at their private clinics.
But Steven Lewis, one of the most respected health economists in Canada, said such reforms are worth considering.
"If you mix the two, if you have a substantial private parallel system, it's very difficult to maintain support for a high-quality public system," he said. "The compromise then is the doctor is either in or out. If a physician wants to practice private medicine, that should be completely distinct [with no access to public health payments], and good luck to you."
Before universal health care can succeed in the United States, Dr. Lewis said, Americans will have to get over hostility toward the idea that a government or nonprofit entity can do a better job than a collection of private companies.
"Our wait lists are coming down, but they're still substantially more than yours," he said. "But your system is twice as expensive. It doesn't insure 45 million people, it underinsures another 45 million, and overall you have a less healthy population. Is that worth sustaining?"
Most Americans are ready for an overhaul, Dr. Lewis believes. But he doubts the health industry that profits from a $2.2 trillion system will go let more of it go to the public sector without a huge fight.
© 2007, The Dallas Morning News, Inc.
