Several years ago, I happened to be in Toronto when the results of a national survey asking Canadians to select the one Canadian they most admired were announced. By universal acclimation–beating out both Alexander Graham Bell and Wayne Gretzky–they selected Thomas Clement “Tommy” Douglas.
“Who is Tommy Douglas?” I wondered.
Every Canadian knows the story of Tommy Douglas. Born in Scotland in 1904, he sustained as a boy a significant injury to his knee, and because his family could not afford surgery, Tommy was virtually crippled by his condition. When his family immigrated to Canada, he remained hobbled by his knee until an orthopedic surgeon took pity on him, used him in a teaching demonstration, and restored his ability to walk normally.
From that point onward, Tommy Douglas vowed that no one in Canada would ever be deprived of access to health care because of lack of funds. He first entered the ministry, becoming a Methodist pastor in the province of Saskatchewan, and then politics, becoming the province’s premier in 1944, roughly comparable to state governorship in the US.
Douglas’s recurring campaign promise was free health care for all in Saskatchewan. In 1947, all hospitals became free. Then, five terms later, in 1961, Tommy Douglas engineered a tax-funded public insurance plan in Saskatchewan to cover all medical treatment, in or out of the hospital. He dubbed this new plan “Medicare,” although its full name is National Health Insurance.
Ultimately, this new plan proved so popular (except among doctors, who went on strike for 23 days, but then capitulated) that the remaining Canadian provinces and territories adopted it as well. Four years later, in 1965, the US copied the Tommy Douglas model along with its name for our own Medicare guaranteed health coverage for those over 65. Other countries, including Taiwan and South Korea, adopted this model later.
Ironically, this model is similar to the 2006 medical care act covering all residents of Massachusetts that former Governor Mitt Romney now regrets having signed into law.
Whereas our own Medicare system is a single-payor model, meaning that doctors and hospitals bill the federal government for reimbursement of their services, the Canadian system remains essentially a regional one. Doctors and hospitals remain private–not government employees or part of a governmental agency–and send their bills to an office in the province where their practice or hospital is located. The funding for all health care comes from tax dollars collected by the Canadian federal government, headquartered in Ottawa, Ontario. Tax money is then distributed back to the provinces.
Medicare for all, upsides and down
The easiest way for Americans to understand Canadian medicine is to think of the phrase “Medicare for All.” The closest we ever came to this would have been the proposed public-option section of President Obama’s Affordable Health Care Act. Private health insurance companies feared (not without reason) that in time everyone would drift to the public option and the Blue Crosses, Aetnas, and Humanas would go the way of the great auk. Threatened with extinction, you can appreciate the health insurance industry’s pulling out all stops (“death committees!”) to kill the public option.
The beneficial aspects of the Canadian health care system seem obvious:
- Everyone living in Canada is guaranteed access to health care at virtually no cost.
- Rates for every service are determined by the government and standardized across the country.
- Negotiation with providers controls costs so that, for example, Canadians pay much (much!) less for the same prescription drugs (same pill, same manufacturer) than we do in the US.
- Because of this ready access to health care, Canadians are simply healthier than we are: longer life spans, lower infant mortality, fewer complications from chronic illness, etc.
- All medical records are available electronically. Canadians don’t (yet) carry their records on one plastic card like the French and Germans, but all points of medical service are linked and your entire health history is readily available to any physician you visit.
- There are virtually no personal bankruptcies because of health care costs.
- Medical schools are subsidized so that young physicians leave with far less debt that their counterparts in the US.
- Malpractice insurance is paid by the government and malpractice suits are really quite rare.
- Overall, surveys among Canadians show high levels of satisfaction with their system.
All this said, the Canadian system has problems that would probably be unacceptable to Americans who have health insurance, leaving aside the 50 million who don’t.
As a percent of Gross National Product (GNP), Canadians pay far less for health care than we do (8% versus our 15%). Nevertheless, providing universal health care is an extremely expensive undertaking, especially for a country whose GNP is tiny in comparison to our own. Faced with less revenue, the government response has been to spend significantly less on health care than the country seems to need.
This has led to shortages on all fronts. Because physician incomes don’t keep pace with the work they have to do, fewer Canadian college graduates seek med school admission and there’s a definite doctor shortage. There’s also less diagnostic equipment and fewer hospital beds.
Such shortages lead to long waits, as described in the book The Healing of America, by T.R. Reid. Although you can see a primary care doctor fairly quickly, it may take months to get an appointment with a specialist, months for an MRI, and months to have elective surgery (like a hip replacement or bypass surgery). Importantly, these shortages and long waits apply to everyone. Even if you have the money, you can’t use it to “jump the queue” in order to have your test or surgical procedure quickly.
Opponents of the Affordable Health Care Act reported that Canadians were coming to the US in droves for health care. But careful investigation found this to be incorrect. Canadians were arriving simply to get warmer. Seriously, data show Canadians don’t come here for care and in fact when Canadian snowbirds come south they purchase health insurance for the length of their stay in the US…using the insurance to get them home in case they become ill.
This situation with shortages and long waits led to an important lawsuit that challenged the “jump the queue” restrictions. A physician filed suit on behalf of a patient demanding that the patient not suffer unnecessarily waiting before having elective surgery. The Supreme Court ruled in favor of the physician and his patient. In response, fearing a two-tiered system in which those who could afford better care would buy it, the federal government voted massive increases in health care spending on all fronts. But funding this health care will remain a challenge in a country that simply doesn’t have the kind of revenue needed to keep up with health care costs.
For myself, I have mixed emotions about the Canadian system. Like our Medicare, the Canadian system will pay for “medically necessary” services. What is necessary is determined by the government, both theirs and, in the case of Medicare, ours. Here in the US, especially with steadily declining Medicare reimbursement rates, primary care physicians with a largely Medicare-age patient population rely on volume, seeing 40 to 50 patients per day to stay financially afloat. That averages one patient every eight minutes.
By Medicare logic, the WholeHealth Chicago model of an hour scheduled for new patients and 30 minutes for follow-up visits, is “medically unnecessary.” I was told exactly that during a Medicare audit when we first opened and it led to my decision to opt out of Medicare. Were we to be reimbursed by its standards (Dr. Kelley and I see about 14 patients each per day), we’d be bankrupt in a month or compelled to transform into an assembly-line medical practice.
And yet Dr. Kelley and I agree with most American physicians who believe that no one should be deprived of health care for financial reasons. Americans should not be tallying up shorter lives or unhealthier babies than our neighbors to the north. There should be no such thing as a medical bankruptcy.
The Affordable Health Care Act, imperfect as it is, seems a reasonable place to start. The process of developing our health care system should give us pause to question our priorities as a nation.
David Edelberg, MD