From the Canadian Medical Association Journal
August 24, 2009
America, embrace health care reform
If power, wealth and talent alone determined how a nation serves the needs of its people, the United States would be second to none in health care. Yet America’s health care system clearly ranks behind those of Canada and most other developed countries. The precious opportunity that US President Barack Obama’s health care reform proposals offer to Americans is currently threatened by partisan disunity, which could once again deny Americans the quality and accessibility of health care that they should receive.
Canada’s “socialist” health system is the favourite whipping boy of antireform lobbyists, who employ fear-mongering and myths about rationing, waiting lists and lack of choice to persuade the American public to accept their status quo as better. As Canadians, we agree that Canada’s health system is not perfect. We have said so many times in CMAJ. Nevertheless, it takes only a few comparisons to show how much better Canada’s health system is than that of the United States — and how much Americans could hope to gain from embracing reform.
Consider the following statistics, taken from the Organisation for Economic Co-operation and Development’s health data for 2006.1 We start with the most basic outcomes any health care system is supposed to optimize: life and death. The life expectancy of an average American is nearly three years shorter than that of an average Canadian (78.1 vs. 80.7 years). That survival gap starts from the moment of birth: infant mortality is higher in the US than in Canada (6.7 vs. 5.0 deaths per thousand live births). Yet the US economy spends — or increasingly, borrows — more than half again as much for health care as does Canada’s (16% vs. 10.1% of the economy). And despite spending so much more, Americans get to see their doctors a third less often than Canadians (3.8 vs. 5.8 doctor visits a year).
While these differences result from many factors, the inescapable truth is that, compared to Canada, America is achieving poor value for money from its health care system, and that is killing Americans. The potency of that truth is the reason why antireform lobbyists are now turning to attack Canada’s system.
As Republican strategist Dr. Frank Luntz puts it, the opposition’s strategy rests on “health care denial horror stories from Canada.”2 Yet the attacks are so absurd and full of fantasy that they would be laughable — if not for the fact that many Americans believe them. Canadians do not, in fact, conduct euthanasia on our elderly; If we did, then Canadian life expectancy would hardly be longer than American. There is no such thing as a “death panel,” neither in Canada’s health care system, nor President Obama’s reform proposal. Nor is it true that in Canada, the system imposes a government bureaucrat between a patient and their doctor to decide what care to provide. On the contrary, that is a routine feature in America’s system, where doctors and patients struggle endlessly with insurance company “bureaucrats” for payment.
The only accusation that has even a shred of evidence, albeit heavily misrepresented, is that Canadians face waiting lists for health care. But that does not mean Canadians routinely die waiting for tests and operations, because the lists are for elective procedures, such as joint replacement surgery, and not for emergency or life-saving care. Prioritizing actually helps ensure the serious cases are seen first.
We cannot condemn strongly enough the intellectual dishonesty of the lobbyists and politicians whose distortions of Canada’s health system camouflage their appalling rejection of reform for uninsured and underinsured Americans. All 32 million Canadians are insured. To be sure, some are unhappy to wait and some are denied treatments it would be better they had; no system is perfect or pleases everyone. But even the least fortunate Canadian is better off than the 47 million uninsured Americans, for whom no treatments are covered and for whom the wait is forever, unless they can afford to pay the health care bills.
If America wants to improve its citizens’ health — as it must — then some negative attitudes need to be turned around. Here are some.
First, the US$1 trillion that the Obama administration says it will cost to cover America’s uninsured over 10 years is not a burden; per capita, it is a screaming bargain. Canada spends about US$156 billion each year to cover fewer people than America’s uninsured. For Congress to hesitate at the outlay is penny-wise and pound foolish, when economic studies suggest that the cost of not investing could be greater still, owing to lost productivity and lost jobs, provided that expanded coverage goes hand-in-hand with cost-containment measures.3,4 Still, when Congress last year dropped US$700 billion at a sitting to bail out Wall Street, it is hard to understand why a lesser amount for public health insurance provokes so much anxiety.
Second, all health care systems ration care — including the US system. The only cruelty in rationing health care comes in doing it the wrong way. When America’s private insurers routinely refuse to cover persons having pre-existing health conditions, that is the worst kind of rationing, aimed mercilessly at those who need medical care most. In Canada, nobody is denied coverage for pre-existing conditions, and there is no cut-off age. Instead, Canada aims to ration medically futile treatments. Where we occasionally make mistakes is in rationing new treatments that in hindsight prove to be useful, not futile. In Canada’s deferential culture, we correct such mistakes slowly by pressuring the public insurer. In America’s litigious culture, suing the public insurer is likely to correct such mistakes more rapidly. That difference, we believe, is likely to make rationing fairer in American than Canadian hands.
Third, certain members of Congress need to get over the bogeyman of “socialist” medicine. Thinking about the military may help. All of America’s closest NATO allies, including those, like Canada, who fight alongside the US in Afghanistan, receive “socialist” medicine back home. Furthermore, when Americans join the military, they qualify for public, government-run health insurance that provides access to care at Veterans Administration hospitals. When Texas Republican Congressman Louie Gohmert described Canadian health care as “a bureaucratic, socialistic piece of crap,”5 was he also implying that America’s soldiers are getting bureaucratic, crappy care?
Fourth, freedom-loving Americans who value making their own medical and economic choices ought to be outraged at how the status quo restricts their choice and freedoms. Because private insurance plans are usually provided through one’s employer, changing jobs often means losing existing coverage and having to re-qualify for new coverage (if one can) under a new plan — a risky move. Private insurance has become the freedom-destroying leash that ties Americans and their families to jobs with less pay or satisfaction than other opportunities that might exist. Canadians, in contrast, can change jobs in our universal, portable public system and stay insured throughout.
Fifth, and perhaps most importantly, America has reached an economic tipping point where the “public option” is inevitable, if only because households (read: voters) find the current system’s costs unsustainable. Canada’s first meaningful foray into public insurance happened in 1940s Saskatchewan, when public anger boiled over as health bills forced families — including many in the middle class — into bankruptcy. That same tragedy is replaying in America, where more than half of personal bankruptcies are medically related.6 This number will only worsen as health costs rise in America, as the population ages and as the US dollar loses ground as a reserve currency. Even if Congress and President Obama fail to achieve a public insurance option this year, in the long term the smart money is against any political party whose name becomes attached to these personal medical bankruptcies.
If Americans find the courage to embrace change, they could enjoy health care that is second to none. Canada’s example has many positive lessons — and a few negative ones — to teach reformers. Lamentably, in the current partisan circus playing out on Capitol Hill, analysis is short and sophistry of the Louie Gohmert variety is long. America must move beyond this if it ever hopes to be able to provide the best care for all its people.
Amir Attaran LLB DPhil
Associate Editor, Editorials
Matthew B. Stanbrook MD PhD
Deputy Editor, Scientific
Paul Hébert MD MHSc
With the Editorial-Writing Team (Ken Flegel MDCM MSc, Noni MacDonald MD MSc and Laura Eggertson BA)
Cite as CMAJ 2009. DOI:10.1503/cmaj.09-1511