Posted on May 18, 2002

Phantoms In The Snow: Canadians' Use Of Health Care Services In The United States


Health Affairs
May/June 2002

Surprisingly few Canadians travel to the United States for health care, despite the persistence of the myth.

by Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer, and Robert G. Evans

A tip without an iceberg?

This study was undertaken to quantify the nature and extent of use by Canadians of medical services provided in the United States. It is frequently claimed, by critics of single-payer public health insurance on both sides of the border, that such use is large and that it reflects Canadian patients' dissatisfaction with their inadequate health care system. All of the evidence we have, however, indicates that the anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg but a small number of scattered cubes. The cross- border flow of care-seeking patients appears to be very small.

Our telephone survey of likely U.S. providers of wait-listed services such as advanced imaging and eye procedures strongly suggested that very few Canadians sought care for these services south of the border. Relative to the large volume of these procedures provided to Canadians within adjacent provinces, the numbers are almost undetectable. Hospital administrative data from states bordering Canadian population centers reinforce this picture. State inpatient discharge data show that most Canadian admissions to these hospitals were unrelated to waiting time or to leading-edge-technology scenarios commonly associated with cross- border care-seeking arguments. The vast majority of services provided to Canadians were emergency or urgent care, presumably coincidental with travel to the United States for other purposes. They were clearly unrelated either to advanced technologies or to waiting times north of the border. This is consistent with the findings from our previous study in Ontario of provincial plan records of reimbursement for out-of-country use of care. Additional findings from the current study showed that a small amount of cross-border use was related to proximal services, primarily in rural or remote areas where provincial payers have made arrangements to reimburse nearby U.S. providers. Finally, information from a sample of "America's Best Hospitals" revealed very few Canadians being seen for the magnet referral services they provide.

These findings from U.S. data are supported by responses to a large population-based health survey, the NPHS, in Canada undertaken during our study period (1996). As noted above, 0.5 percent of respondents indicated that they had received health care in the United States in the prior year, but only 0.11 percent (20 of 18,000 respondents) said that they had gone there for the purpose of obtaining any type of health care, whether or not covered by the public plans.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these "zombies"-ideas that, on logic or evidence, are intellectually dead-that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.


Comment: This excellent study refutes the false generalizations that have been extrapolated from the embellished anecdotes of Canadian medical refugees in the United States. Debates on health care policy should be based on the best factual information available regardless of whether or not those facts support individual ideological viewpoints. This important study should be downloaded and made readily available to refute those that insist that single payer approaches should be dismissed immediately without further consideration merely because of the fictional massive medical migration from Canada into the United States.