Health care north of the border
By Marshall Helmberger and Tom Klein
November 20, 2007
Timberjay, Ely, Minnesota
While Americans often don’t agree on much when it comes to politics, on one particular issue we really do seem to share a common view. Recent polls show vast majorities, up to 90 percent, of Americans agree that the nation’s health care system is in need of serious reform.
High costs and the growing numbers of uninsured and underinsured Americans are at the top of the list of complaints. While Americans clearly don’t agree on the best approach to resolving such problems, many have pointed across the border to Canada as a model to fix what’s wrong with American health care.
The merits of the Canadian style of health care have been the subject of intense debate in the U.S. for months, sparked in part by Michael Moore’s recent documentary film, “Sicko”, which highlighted Canada’s system among others. Free market advocates have shot back, pointing to studies that show growing dissatisfaction among Canadians over long wait times for some types of medical care.
So what’s the real story?
We didn’t need to go far to find out. Last month, Timberjay investigative reporters Tom Klein and Marshall Helmberger hopped across the border to Fort Frances to talk to health care professionals, business leaders, politicians and average Canadians, to find out what lessons America can learn from health care north of the border.
A few surprises
While Americans often talk of Canada’s national health system, the first surprise you’ll learn from talking to Canadians is that, in fact, Canada does not have a national health care system. The federal law, known as the Canada Health Act, sets guidelines for health care in Canada, but leaves each province to determine how to meet those objectives.
In Ontario, residents don’t look to the federal government for their health care — they look to the provincial government in Toronto, which manages the Ontario Health Insurance Program, or OHIP.
That’s probably not surprising given that universal health care in Canada was a creation of the provinces in the first place. In 1946, under the leadership of Tommy Douglas, the province of Saskatchewan first implemented provincial-wide health coverage, a model that spread to other provinces before becoming the basis for national policy beginning in the 1960s.
While the details of Canadians’ health care varies from province to province, the basic outline for OHIP is surprisingly similar to a system that is already well established here in the U.S. — Medicare.
Like Medicare, OHIP pays for hospitalization, doctors’ visits and most medical procedures but, for working-age adults, things like prescription drugs (unless they’re administered in a hospital), some eyecare, or dental or chiropractic services, are not covered. Most of these additional services are covered for Ontario seniors, and typically for children as well. As with many seniors in the U.S., most adults in Ontario between age 18 and 65 purchase supplemental insurance to cover any health-related expenses not covered by OHIP.
Such policies are significantly less expensive, however, than the broader health insurance purchased by most working age Americans, and most, as in the U.S., are paid for by employers. Jim Cummings, the publisher of the Fort Frances Times, says such policies cost him about $70 a month per employee for family coverage. That amounts to about $840 a year, or far less than the $13,000-$16,000 annual premium typical for full family coverage in the U.S.
The Canadian system, which is actually called Medicare in Canada, is similar to the U.S. style of Medicare in other ways as well. Like Medicare, the Canadian system involves public financing, but typically private delivery of care. Most hospitals and clinics are publicly-owned and funded by the province, but are run by independent boards that set priorities for health care spending. In addition, most doctors work independently on a private-fee-for-service basis, just as in the U.S.
The view of Canadians
We quickly discovered one trend among residents of Ontario. If an American asks them what they think of their own health care system, the response of Mike Williams is fairly typical: “I love it.” Williams is a former emergency medical technician, who lives near Emo. He was dining with friends last month at a restaurant in downtown Fort Frances, when we asked them to share their views.
Such a response may reflect more a sense of national pride than a full and complete picture of Canadians’ real attitudes. While every Canadian we spoke to expressed support for their system, and view it as superior to the U.S. model, when asked more specific questions, several did point to the waiting list, known as “the queue” in Canada, as an issue, but most didn’t see it as a serious problem.
Perhaps that’s because for Canadians with more immediate medical needs, waiting is the exception, not the rule. “In acute emergencies,” you jump to the front of the line,” said Cummings, who related the recent case of his wife, who had experienced chest pains. “She got immediate care in Fort Frances,” he said. “And when her local doctor decided she needed surgery, they had an operating room booked the next day in Winnipeg. They flew her there and sent a nurse along as well. And, except for the ride to the airport, it was all paid for by the province.”
Pam Cain had a similar experience last year, when an ovarian cyst proved to be cancerous. Cain, who manages a provincial history museum in Fort Frances, had been experiencing pain and made an appointment to see her doctor.
When that doctor couldn’t determine the problem, she saw a specialist two weeks later, who determined she had a cyst, which was most likely non-cancerous, but still required surgery. The surgery was scheduled for about six weeks later. But before getting there, she experienced more severe pain and took herself to the local emergency room. At that time, she was referred across the border to use the CT scanner at International Falls, which isn’t unusual for Canadian patients in the Fort Frances area, because Fort Frances doesn’t yet have a CT scanner of their own (the community has recently raised money for one and its installation has been approved by the province).
When Cain’s CT scan suggested her cyst was likely cancerous, her wait for surgery was over. “I was flown to Winnipeg for surgery in less than half a day,” she said. Since then she’s gotten regular follow-up care in Winnipeg, with the province picking up the cost of her mileage in addition to the care she receives.
A year later, she’s doing fine and hasn’t had any significant medical-related bills to pay.
The same probably couldn’t be said for Cain if she lived south of the border, notes John Rafferty, a provincial politician with the New Democratic Party, or NDP. Not only would Cain have likely been faced with thousands of dollars in medical costs, even with insurance, Rafferty said she would also face the potential of losing medical coverage all together.
Waiting times and politics
As a critic of the Liberal Party that’s currently in charge of Ontario’s health program, Rafferty isn’t shy about expressing shortcomings of the system. He acknowledges that health care in Ontario, just as in the U.S., remains a major political issue as the government and the public weigh the competing merits of affordability and access. Waiting times remain the primary issue with voters, he said.
American critics of the Canadian system frequently point to waiting times for appointments or some procedures as a failing of nationalized systems in general, but data from countries like Britian and France suggest the problem is a more pronounced one in Canada than elsewhere.
Wait times are most common for sufferers of chronic illnesses, who may have to wait weeks, or in some cases, even a few months, for appointments with some specialists.
Yet wait times in Canada may be fueled more by the remote nature of much of the country than anything else. “Doctor recruitment is a big issue,” said Wayne Woods, chief executive officer of the Riverside Hospital system, which operates four hospitals in northwestern Ontario. “Big cities seem to have enough, but more remote areas are crying for doctors,” said Woods.
Fort Frances is a case in point. Woods said the community has budgeted for 14-15 doctors, but can currently only find 11 willing to work there — and the doctor shortage means patients in the community wait longer than they otherwise might for appointments.
Woods said the remote nature of many smaller Canadian communities has long been a factor behind the doctor shortage. Indeed, doctor shortages in rural Canada in the 1940s were in part responsible for the creation of Canada’s publicly-funded system.
Attracting doctors can be even more difficult today than it was then. In an era when most doctors’ spouses also work, and are typically professionals as well, it means a community must often find employment for two, rather than just one. “Finding work for the spouses of doctors is one of the biggest challenges,” said Cummings, at the Times.
Finding doctors for remote communities isn’t a problem unique to Canada. Hospital administrators in northern Minnesota and other rural parts of the U.S. note similar difficulties as many doctors prefer the lifestyle available in larger cities to that found in small, isolated communities.
The wait for appointments in some cases has prompted Canadians to increasingly make use of emergency rooms, where wait times are little different than in the U.S. Cummings said the province has responded to the political demands of patients by instituting a policy that requires that patients receive attention by a nurse-practitioner within ten minutes of arriving at an emergency room. While the policy may have pleased most Canadians, some health care officials worry it may increase costs in the long run.
One factor that apparently hasn’t hampered recruitment is doctor pay. While some in the U.S. believe otherwise, doctors in Canada don’t work for the government. They work for themselves, typically on a fee-for-service basis under contract with hospitals and clinics.
And most Canadian doctors earn salaries that are comparable to doctors in the U.S. According to Woods, most general practitioners earn $150,000-$175,000 a year. And specialists earn much more than that. “A million dollars isn’t unusual,” said Woods. “The sky’s really the limit.”
Love for Canadian system not universal, but system remains highly popular
The NDP’s Rafferty admits that not everyone in Canada loves their health care system. “There are people in Canada who think the U.S. system is a good one. They’re generally the ones with money,” he said.
Some wealthy Canadians, who are not content to wait for procedures, do head to the U.S. or other countries for care. “I know people who go to the Mayo,” said Rafferty. “The U.S. does a good job of emergency medicine and if you have money, you can get access to the U.S. system.”
While conservatives in Canada did attempt a few years ago to significantly alter the system now in place, Rafferty said the move was soundly rejected by Canadians.
The popularity of the Canadian approach to health care was probably best expressed in 2004, when the CBC asked Canadians to vote in a contest to select the greatest Canadian in history. The winner? Tommy Douglas, the late prairie populist, NDP leader, and father of Canada’s modern health care system.
That popularity doesn’t surprise Rafferty, who says the system works well for the majority of Canadians. “Not only is everyone covered, but we see that our system is actually cheaper than in the U.S.” he said.
And for many Canadians, the issue is who has the power over their health care decisions.
“You have the insurance companies making the decisions. That’s what’s scariest to me about the U.S. system,” said Teresa Hazel, the director of the Riverside Foundation for Health Care in Fort Frances.
While the provincial governments sets overall budgets for health care, the allocation of those funds is determined by separate boards made up of citizens, health care professionals, and other stakeholders in the system. Many Canadians believe this approach makes the system more responsive to the needs of communities and patients than a system motivated by insurance company profits.
Rafferty said Canadians are less reluctant than many Americans to take an all-for-one and one-for-all attitude when it comes to social benefits, like health care. There’s a difference in mindset,” said Rafferty. “We know that if you factor in all the taxes, we probably pay considerably more than Americans. But that’s a tradeoff that Canadians are willing to make.”
[PNHP note: Actually, Americans pay the highest taxes for health care in the world, in addition to the highest out-of-pocket costs, but we don’t receive value for our money. Canadians have modestly higher taxes overall than Americans, but in addition to universal health care, those pay for things like free higher education, roads, and many other benefits. See “Paying for National Health Insurance - And Not Getting It” Woolhandler and Himmelstein, Health Affairs, July/August 2002]