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September 20, 2009

Canadian health care as good as American, 47% cheaper

Foes of health care reform are making up all kinds of scurrilous nonsense about Canada's universal health care system.

Canadians have slightly longer life expectancy than their American counterparts and are just as likely to survive heart attacks, breast and cervical cancer, and childhood leukemia:

Sept. 18 (Bloomberg) -- Opponents of overhauling U.S. health care argue that Canada shows what happens when government gets involved in medicine, saying the country is plagued by inferior treatment, rationing and months-long queues.

The allegations are wrong by almost every measure, according to research by the Organization for Economic Cooperation and Development and other independent studies published during the past five years. While delays do occur for non-emergency procedures, data indicate that Canada’s system of universal health coverage provides care as good as in the U.S., at a cost 47 percent less for each person. [Bloomberg]

The U.S. had the highest rate of deaths preventable by health care in the entire OECD, 110 deaths per hundred thousand people. Canada had the sixth-lowest rate, 77 deaths per 100,000. 

Canada covers everyone with results as good as, or better than, the U.S. health care system, all for 47% less per person.

I grew up in Canada and I can attest that the system offers excellent care--equaling or surpassing any medical care I've received in the states, and with none of the bureaucratic nightmares of the private insurance system. 

Opponents of single payer hold up the specter of waiting lists in Canada. You might have to wait a few extra weeks to get an elective knee MRI, or for elective surgery. But you will get it, and you won't get a bill, or be told that it's not covered after all, or find out that your rates are going up because the test unearthed a preexisting condition.

Long waiting lists are hardly the norm, however. Let's not forget that the U.S. system makes a lot of people wait, too.

How many times have you put off treatment while you searched for a specialist that covered your kind of insurance, or delayed treatment because you didn't have insurance, or even had to wait for a procedure in the hospital while your caregivers wheedled and bargained with an insurance company bureaucrat? I know I've spent more time in insurance-induced limbo in the U.S. than I ever did waiting for health care in Canada. 

In B.C., where I grew up, premiums are about fifty bucks a month. Your rates don't go up if you're older, or if you have a preexisting condition. At fifty bucks a month, a family of four would pay $2500 a year for insurance. In the U.S. it would cost $13,000 a year to provide less comprehensive, less secure coverage for the same family. 

Opponents of health reform talk about freedom and lower taxes. Well, think of the financial freedom that comes with saving thousands of dollars a year on health insurance. In Canada people are free to pick the jobs they want instead of the jobs that have health insurance. Canadians can start their own businesses without having to worry about the spiraling cost of health insurance for their employees.

And no, Big Brother doesn't try to micromanage our lifestyles in order to save public money. Unlike here in the U.S. where companies are assigning insurance company "life coaches" to badger their employees to lose weight and quit smoking.


Yes, Canada has the 30th best health care system in the world, whereas the US is 37th. So Canada is better. The point is, in countries like France or Japan or Singapore, all of which rank in the top 10, you don't even have to wait for elective knee MRI. In French hospitals, waits are comparable to or lower than those of American ERs, and the cost is €21 per visit for people who don't have private insurance.

In France there is something like life coaches, only less obnoxious. The government is more interventionist about food in public schools, planning students' meals. There was even a furor a few years ago when it turned out the only hot option on some menu included pork. A few years earlier there was a similar furor about this happening in one of the German-speaking countries - I think Switzerland, but I don't remember. It's not like in the US, where McDonald's sets up shop at schools, and even a soda tax is controversial. (Conversely, in the US anti-smoking laws are much more accepted, and unsurprisingly smoking prevalence ranks second from the bottom in the OECD.)

I would not soft-pedal the issue of expected lifetime. Death, and age at death, are things that are pretty easy to objectively measure, compared to all the waiting-list/elective-surgery hoo-hah. 4% better, over a country-sized population, is a Big Deal. And if it's not caused by our health care system, what the heck is the cause, and how about we see about fixing that?

Once again, you have entirely missed the point! Insurance CEOs have unique mental health issues that require they earn at least 10s of millions of dollars per year. Sure, a public option or single-payer system may help some currently uninsured individuals, but who are we to deprive the CEOs of their mental health just so that some unskilled worker can get treatment for heart disease?

"Canadian health care as good as American, 47% cheaper"

I've lived 30 years in Canada and 20 in the US. Been there and done that with both health systems. Under big corporation and small business coverage. So my take:

Canadian health care is 47 times better than American, and 47% cheaper.

Because the Canadian system is not based on profit and financial measures. It is based on fundamental human and societal values - for the patients. It is not an entitlement - everybody pays via special payroll deductions. It is a share-cost approach to achieve universality of coverage.

With the US system, all the caregivers need to do is to satisfy Wall Street expectations and maximize their luck with malpractice premiums and lawyers. These are achieved by raising prices, reducing coverage, and disqualify enough people. It works - for them. It is after all designed for the caregivers. Not the patients.

With the Canadian system, non-emergency and elective treatments are delayed but never denied. Private insurance companies are kicked out - thus eliminating their horrific stranglehold. This, along with smart implementations refined over decades, produced a universal system that's equal to the best in the world at a very reasonable cost. But it delivers universal coverage to 100% primary care, no paperwork, no personal bankruptcy, and absolute peace of mind. To me, I call that 47 times better the the US system.

But Wall Street will be 47 times disappointed with the 'lousy profitability, awful, socialist, backward, failed, inhumane' system up north. I can only laugh at these stupid assO.

I would not soft-pedal the issue of expected lifetime. Death, and age at death, are things that are pretty easy to objectively measure, compared to all the waiting-list/elective-surgery hoo-hah. 4% better, over a country-sized population, is a Big Deal. And if it's not caused by our health care system, what the heck is the cause, and how about we see about fixing that?

There are other public health issues than health care - for example, nutrition, smoking, and pollution. I believe the WTO measures the difference by publishing separate rankings for overall system performance (where France ranks first) and goal attainment (where Japan ranks first). The US ranks in the 30s on both lists.

This, along with smart implementations refined over decades, produced a universal system that's equal to the best in the world at a very reasonable cost.

Canada ranks 30th worldwide in performance. It's actually much closer in the ranking to the US than to France.

Canada's health care system has been deteriorating since the 80s when federal transfer payments to the provinces stopped keeping up with population growth. Every federal government since (and including) Mulroney, and a few provincially, have been nudging the country toward a US style health care system. My general impression is that the Liberal and Conservative parties at the federal and provincial levels have very little interest in preserving Canada's public health care system and bit by bit are doing what they can to let America's "free market" health insurance industry move in and take over.

The plan seems to be to erode public health care to the point where people start begging to pay out of their own pocket; and some citizens, without realizing what this means in real terms, are doing just that. Brian Day, the past president of the Canadian Medical Association ran on a platform of privatization. He's an advocate for private clinics that charge exorbitant fees, and doctors working outside the public system. A handful of private clinics are already running and provincial governments turn a blind eye to them. The only time the province of BC challenges the existence of a private clinic is if the public gets in an uproar about it. In some provinces, non medical health services have already been privatized - like cleaning, laundry, food and nutrition, and security in hospitals. In BC, this is the case and the standard for all of these services is significantly lower. Big multinationals pocket government money and provide the barest essentials, sometimes not even that. High turnover minimum wage workers employed by Sodexho aren't properly trained and have no commitment to the job. BC's government is also doing sneaky things like hiring more LPNs to replace RNs, because they cost less. In BC, our health authorities are underfunded to the point where they're cancelling thousands of surgeries, closing essential services for patients, and even laying off medical staff. This is all being driven by right wing politicians who call themselves Liberals. The same ones who have no trouble funding the Olympics.

Lesley, the situation you describe as a horror story - private clinics and doctors working outside the public system - is exactly how health care works in France, or for that matter almost every developed country outside North America. France even charges some fees for public health services and prescription drugs; it expects people to buy private insurance if they want to cover those costs (but the low costs - an overnight hospital stay involving surgery costs €120 - guarantee low premiums), while subsidizing private insurance for those who can't afford it.

In Canada, the (legit) fear is that attacks on the single-payer system will not lead to French outcomes, but instead to American outcomes, because of political-economic factors in relation to the United States. Also, France has a number of socioeconomic and political factors that make it quite different, as I understand it, from the US *or* Canada.

In any case, the point is moot. It is politically necessary now to argue simply for the abolition of private insurance in the USA, not attempt to "compromise" for ways of preserving it, because all reasonable compromises have been shwon to be completely unacceptable to it, in that by definition they reduce profitability. Hence, expropriation and single-payer is the order of the day.

And I would like to reiterate Lindsay's experiences in that I too am a Canadian who grew up under the Canadian health care system, but is now under the US one. It is very liberating to know that there is no work to be done for coverage other than (in Ontario at least) to save a couple of utility bills proving residency---which for most they never look at---and do my income taxes.

It's even more liberating to know that there's no work to be done for coverage other than (in Monaco at least) to give them an address to send the €21 bill to.

I don't know what the general fears in Canada are - have the Tories ever proposed actually scrapping Medicare, instead of just augmenting it with private add-ons? Besides, I was responding specifically to Lesley, who told horror stories of a situation that is precisely how Europe does health care. Think of it as the converse of telling an American that single-payer health care will make the US look more like France and not Cuba.








Alon: I was responding to you responding to Lesley. I'm not sure Lesley is correct in suggesting that private clinics are a new phenom in Canada, but I agree with the spirit of her post.

It is already the case (and has always been the case) that add-on and even basic medical services and insurance can be obtained through private channels in most if not all of Canada. In Ontario, you can show up to a health care provider and claim that you are in some way unable to produce proof of public coverage. Some establishments may turn you away (I don't know) but there are definitely providers that will find alternate arrangements to obtain payment, including hospitals. I don't know about the rules in BC, I assume them to be relatively similar to Ontario.

The only limitation is that providers who choose to accept both public and private coverage are not permitted, as I understand it, to give private payers higher priority in service. (I'm not sure how the Chaoulli decision of the Supreme Court affects this in Quebec.) Most Canadians support limitations on queue-jumping for private payers, reasonably assuming that they would not be among those able to afford the largest queue jumps.

While all full-service hospitals in Canada are public (there wouldn't be enough clientele under the current system to support hospitals that don't take public insurance and its attendant legal limitations), there are clinics that are private and also do not accept public insurance. These do not have any such limitations, at least in the jurisdiction they exist. They also only serve a few, as public system generally delivers outcomes that even the well-to-do among the upper middle class mostly depend on it.

This is key to the debate on health care in Canada. Its most passionate moments happened during the 80s and 90s where NAFTA and the deficit were matters of major political attention, the latter being nearly an obsession among the Canadian chattering classes, and the former (rightly) encompassing all the fears of the Canadian nationalist/populist left, yours truly firmly included.

At that time there was a big push by the ideological right (and the sneaky/servile ideological center in the Liberal Party) to balance the books on the back of the health care system, which many Canadians correctly feared would lead to a situation where the public system would be unable to handle the burdens of care equitably and at high quality. This push was led, and is still led, by a coalition of right-wing ideologues and self-interested doctors---who also pushed, via medical cartelry, for a reduction in admissions to public medical colleges (and have managed to stall the liberalization of recognition of overseas credentials, leading to the common MD taxi driver phenomenon). This too would mean that the expansion of a private system would come very much at the expense of care for those reliant on the public system.

Canadian attachment to the system (and, to be fair, the desire of non-insurance-based industries, foreign and domestic, to avoid US health care complexity and expense) was for once capable of holding back most of that thrust, the pressure having been immense in my memory. Even so, while most of the doctors I know (and I'm related to a sizeable number) support the public system, a very vocal subset of doctors supports the kind of undermining I mention above.

As for the Tories, Stephen Harper was pretty much at the heart of the campaign to undermine public services in general for ideological reasons, including his involvements with the National Citizens Coalition, and so on. These organizations and campaigns have a great deal of ideological attachment to the "Americanization" of Canada, and do not intend to institute a system like that of France, which I maintain would be mostly redundant.

So what some provinces have done is to permit the spread of private medicine, though not as radically as we feared in the 90s. Whereas in the Canadian context this is a sign of political danger to the public system.

Well, unless Canada intends to scrap Medicare, any increase in acceptance of private insurance will make it more French rather than American.

The restrictions on queue-jumping come from the fact that in Canada and Britain private insurance is made unaffordable for most people. I'm not sure about statistics in Canada, but in Britain only about 15% of the people have private add-ons. In France the corresponding figure is about 90%, because the single-payer system is perceived as just basic coverage, rather than the be all and end all of health care.

I don't think trying to adopt the practices of the number 1 system when you're ranked 30th is redundant.

(P.S. the deficit concerns were valid. So were the solutions. In times of growth, it's best to work on reducing the debt-to-GDP ratio, so that when the recession comes, you have more money to spend on fiscal stimulus. Leftist economists sometimes charge that this reduces economic growth, but Canada's per capita GDP growth in the austere 1993-2008 period was second highest in the G-7, trailing only Britain - and its tight economic policy in part helped prevent the bubble economies of the US and Britain.)

I know that about 30% of health care money in Canada comes from individual pocketbooks and insurance plans. I don't have a statistic as to how many people are covered by private add-on insurance, in Canada, but anecdotally I suggest that the number is sizeable as many large employers offer it. Until I turned 25 I was covered by a generous and highly affordable add-on private insurance plan available to my parents. I don't know how much of basic care it would cover as on the occasions when my family had to use the system, we relied on the public system---but we did use the insurance for individual hospital suites, etc.

I suggest that the difference between France and Canada in health care outcomes may not be related to the mechanism of health care delivery at a national level. Canada has a few very specific, endemic problems that affect large sections of its population that do not apply in France. The biggest one I can think of is the life expectancy of the approx 1M aboriginal population, which at the last census (2000) was about 10 years less than the overall Canadian population. Private insurance will not directly help this population, but this gap surely drags down Canada's overall health performance.

Finally, it is a pipe dream in the Canadian context to assume that health care reform will lead to a French-style system and French-style outcomes. As I said, almost all forces in Canada that push allegedly for European-style systems have a very transparent agenda and have close ties to US groups that are associated with Aetna and BCBS. So from a political standpoint the only option on this continent is to hold the line and minimize the intrusion of private interests.

Mandos, the ranking distinguishes goal attainment (i.e. healthy population) from overall system performance (i.e. good health care). On goal attainment, Japan naturally ranks first, with its first-in-the-world life expectancy, low infant mortality, and rock-bottom cancer rates. On overall system performance, France ranks first, and Canada ranks 30th. It's not native Americans - if having oppressed minorities dragged down system performance, France would be 50th, with its 30%-unemployed Algerian population.

Private insurance doesn't have to be paid out of pocket. In the US, there are plenty of people in deep poverty; those get Medicaid, which is essentially private insurance paid by the government. France has such a system, together with single-payer; the advantage of this combination is that insurance company only have to pay what the government won't, allowing them to keep premiums down (which is important, since France has no mandates).

The transparent agenda doesn't matter too much. Private interests in Canada have no way of getting Medicare privatized. As far as I can tell, the politics involved would be as intricate as those of Social Security privatization in the US, which went nowhere even though Rove is a better politician than Harper will ever be, and the Republicans actually had a majority. Allowing more private add-on insurance is second best for right-wing interests; It would not be able to take over Medicare anyway without good cost control, while at the same time, cost control requires regulations that would force Canada to be more like France or at worst Switzerland.

I realize we are talking about healthy populations, which is why I mentioned the life expectancy at birth of Canadian aboriginals.

I would be really surprised if there were as large a gap between Algerian-French and white French as there is between aboriginal and non-aboriginal Canadians. For one thing, while Algerian-French live in the suburbs, they still tend to live in densely populated areas with, presumably, access to a reasonable distribution of health care options. While much of the Canadian aboriginal population lives in cities too, a large chunk lives away from cities in areas under-served by anything at all, private or public, medical or otherwise. And have high amounts of chronic public health problems, like alcoholism and child neglect and infant mortality and abuse. (And incidentally, the USA has only half the native population by proportion.)

Generally, even compared to immigrants, indigenous peoples are almost always screwed six ways from Sunday for centuries.

In any case, my point was that I'm not convinced that method of funding is really the difference between the health of populations in France and Canada; in fact, your mention of the Algerians in France makes it even less obvious that this is the case, as they are less likely to have access to private add-ons than white French. I used the aboriginals in Canada not as a full justification for the difference, but one factor among possible many that are not accounted for by a public/private funding distinction, especially since the method of funding is not all that distinct in real terms!

Disputing your assertions about Canadian politics would necessary lead to an extended discussion about Canadian federal and provincial Parliamentary procedure, the Canadian constitution, and so on. Consequently, I will simply beg to differ on the matter, as someone who lived through these very intense and emotional national discussions when I was in Canada. Suffice it to say that it is much easier in Canada to institute and/or abolish things than it is in the USA. That is possibly why Canada solved the problem earlier than the US did.

I thought Canada solved the problem because it left social services to the provinces, making it easier for Saskatchewan to introduce single-payer health care.

While Algerian-French people are likely less covered by private insurance than white French, remember that in France a) the basic public plan is pretty good, arguably better than what most insured Americans have, and b) the government subsidizes add-on insurance for the poor. I'd argue that the proliferation of public hospitals in France ensures that it has more equality in health outcomes rather than less.

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