A Canadian Perspective on Children’s Health Care
March 12, 2010
Posted by chcablogadmin in : Healthcare Reform
You won’t want to miss this insightful article from Alan about the differences between the U.S. and Canadian health care systems. It’s one of the best perspectives I’ve heard. Now, who do we need to talk to in Washington? – Don
Alan Goldbloom, M.D.
by Alan L. Goldbloom, MD,
President and CEO
Children’s Hospitals and Clinics of Minnesota
Although I have spent the last seven years at Children’s Hospitals and Clinics of Minnesota, virtually all of my previous professional life has been spent in my home country of Canada, where I have worked in private practice, in an academic full-time pediatric position, and finally in an administrative leadership role at The Hospital for Sick Children in Toronto. My experience has given me a perspective on the two systems, and I offer a few thoughts…
With the unfortunate politicization of the American health care debate, various options tend to be categorized as representing extremes of either good or evil. The Canadian system is often demonized by the political right as “socialized medicine” or “government-run health care” (an interesting accusation since 45% of health care in the U.S. is “government-run”). When we compare health systems from country to country, we have a tendency to do so by comparing the worst horror stories from each (and every country has its share), rather than by looking at broader-based indicators of success.
I would like to correct a few common misperceptions about the Canadian system:
- Socialized medicine is a misnomer. Canada has socialized health insurance, but most of the physicians are in private practice. As in the U.S., the physicians negotiate fee schedules with the insurer – a provincial government agency – approximately every three years. The doctors do not work for the government.
- Canadians have free choice of physicians or hospitals. Everyone is “in the network.” The government does not dictate whom you can see.
- Unlike the U.S., the insurer does not get in between the patient and the provider. There are no “prior approvals” required for surgery or other treatment. The common accusation that the government becomes involved in your health care decisions is simply false. In fact, the insurer is pretty much invisible. Newborn babies are registered in the system at birth and, from that point, are insured for life. No limits, no exclusions for pre-existing conditions, etc.
- The suggestion that government involvement creates more bureaucracy is hard for me to fathom. Anyone who has tried to navigate the complex waters of Medicaid (which varies from state to state), Medicare, C.M.S., or indeed the requirements of insurance companies in order to qualify for payment will understand that health bureaucracy has become an industry unto itself in the United States. I maintain that the regulatory complexity of American health care is hundreds of times greater than anything I had encountered during my years in Canada.
When I practiced pediatrics in Canada, one of the great joys was the fact that I never had to consider whether any family could afford the care I was recommending – whether it involved specialist consultations, surgery, or hospitalization. It was simply a non-issue. People enroll in the system only once – when they are born, or when they immigrate to Canada.
One of the frequent criticisms of Canada is there is rationing of care. It’s true! And, of course, it’s true in the United States as well. The difference is in the U.S. the rationing is determined by insurance and economic status, whereas in Canada it is determined more by urgency of medical need. The renowned health care economist Uwe Reinhardt wrote a brilliant discussion of “the R-word” (as he described rationing) in his Economix blog in the New York Times on July 3, 2009. This link will take you to it: http://nyti.ms/gaZCY. He makes the point that even a free market is simply a form of rationing – it’s rationing based on an individual’s ability to pay. If one accepts the current trend of increasing health care expenditure is simply unsustainable in our economy, then some form of rationing or priorization of resources (based on need, evidence of efficacy, etc.) is ultimately required in any viable health care system.
The issue of outcomes is often touted as the reason why some countries have better health care systems than the United States. Outcomes are complex things to measure, and in general are a reflection of many different factors including education, economic stability, levels of poverty in a society, etc. The Organization for Economic Cooperation and Development (OECD) tracks a wide range of health statistics from developed, industrialized countries throughout the world on an annual basis. Currently, the U.S. spends about $7290 per capita on health care versus $3895 per capita in Canada. 45% of American health costs are paid by the government versus 70% in Canada (so the difference is not as great as one might think). The United States has 2.42 MDs per 1000 population while Canada has 2.18. The U.S. has four times as many MRI machines per million population (25.9 vs 6.7 per million), but it’s hard to show the benefit in health outcomes. Canadian life expectancy is a full two years longer than that of Americans, and infant mortality in Canada is 5 per 1000 live births vs 6.7 in the U.S.
More Canadians than Americans are smokers (18% vs 15.4%), but fewer Canadians are classified as obese (15% vs 34%). Disease statistics, listed as causes of mortality, vary from condition to condition. You are slightly more likely to die of respiratory disease or diabetes if you are in the U.S., but slightly less likely to die of cancer. The differences are relatively minor.
There is one characteristic shared by both countries. In both Canada and the United States, complaining about the health care system has become a national sport. But as much as Canadians constantly demand improvements to their system, they would never give up universal health insurance. It has become as sacred as free speech, and is viewed as a fundamental right of citizenship.
With all its flaws, I remain a champion of the Canadian health care system because I believe it is fundamentally more fair, and is based on a nationally accepted value statement that everyone has the right to health care. However, I am not so naïve as to believe the Canadian system could work in the U.S. During my time here, I have come to appreciate that the cultures of the two countries are more different than I had realized. There is certainly a very different attitude in the U.S. toward the idea of government involvement in anything, and a much greater reliance on consumerism and free enterprise to solve some of these problems.
In fact, you certainly don’t need the Canadian system to solve American health problems. Most of the industrialized countries – with the notable exception of the U.S. – have found some way to provide universal health care to all their citizens, either with public plans or with public-private combinations. Among all of these nations, we could surely adapt the elements that have worked best, rather than try once again to re-invent the wheel. To get to that point, however, requires a national commitment to the value proposition that health care – good health care – is a fundamental right. We have accepted that premise for the education of our children, at least through elementary and high school, and have accepted that our taxes should pay for it. We need to make that same national commitment to health care. And if we can’t agree to do it for the entire population, let’s at least start with children. It’s the best health investment we can make.
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