Despite the partisan war in Washington that shut down the federal government
this week, President Barack Obama has succeeded in implementing the first major
health reform in the United States in nearly 50 years, as the Patient Protection
and Affordable Care Act goes into effect. Even though its most virulent critics
raise the spectre of “Canadian-style” health care, “Obamacare” does little to
change the enduring differences between the two health care system. What,
exactly, does “Obamacare” look like compared to Canada?
Not single-payer: Canadian critics tend to rail against
“two-tiered” medicine, but in fact, the U.S. has a multi-tiered system. And
despite the hype on both sides of the Congressional aisles, Obamacare keeps the
same complex structure in place, while adding another layer through the
introduction of health care “exchanges” for uninsured Americans. But the
majority of Americans will continue to access care through a variety of health
insurance plans made available or subsidized by their employer; nearly 50
million elderly and disabled through the federal Medicare program; another 60
million lowest-income through state-federal Medicaid arrangements.
Not universal coverage: Health care in Canada is based on a
simple proposition: every legal resident is covered through a publicly-financed
provincial or territorial plan. The individual mandate, derived from a
Republican precedent in Massachusetts, stands in stark contrast to Canada’s
universality principle. Even though Obamacare broadens coverage, the individual
mandate relies on a fundamental insurance principle – care depends on type of
coverage – and compels Americans to purchase insurance to access care. Americans
now have more affordable insurance options and subsidies to cover their costs,
and the lowest-income may be eligible for public coverage through the expansion
of Medicaid. Still, despite the crush of online traffic as enrolment began
Tuesday, only half of the estimated 40-plus million uninsured will be affected
by Obamacare.
Not “national” health insurance: One of the hallmarks of
health care in Canada is that, although each province and territory administers
a health plan, everyone can expect to be covered for a comprehensive range of
services, no matter where they live. And the federal government is expected to
chip in to provincial coffers to make this happen. There’s plenty of
intergovernmental friction as a result, but nothing like the fractured
federalism of the United States. The implementation of Obamacare will further
exacerbate regional and state differences, mainly as a result of the Supreme
Court decision to curtail the federal government’s obligation for states to
expand their Medicaid coverage. As a result, only about half of the states have
chosen to sign on to the new Medicaid program.
Not equal access: There’s been some controversy in Canada
lately over wait times and access to timely care, but this pales in comparison
to the wide gulf that exists in access to care in the United States. Obamacare
tries to address this in its provisions for insurance reform, such as lifting
pre-existing conditions and limits on co-payment. But for all of the emphasis on
affordable care, the new law reinforces the notion that access depends on how
much you can afford, not how much you need. In the health insurance exchanges,
the price of premiums will depend on your age, health, income, and on whether
you opt for a bronze, silver, gold or platinum coverage. In Canada, access to
necessary health care services is not a competitive sport.
Not cost containment: The sharpest critics of Obamacare
argue it does little to address the fundamental challenge of cost control. The
new law includes a review of Medicare reimbursement and the expansion of
Accountable Care Organizations to reward cost-effective care. But it doesn’t
grapple in a systematic fashion with the overall inefficiencies in health care
delivery and financing, the administrative burden of multiple payers, providers
and plans, and the cost pressures of defensive medicine. Governments in Canada
know that health care is a searing financial responsibility, but they have at
their disposal cost containment measures – monopoly fee negotiations with
providers, global budgets for hospitals – that remain unfathomable in the
American context.
Obamacare is a huge step in American health reform and, if it seen to improve
the system, will represent a major victory for Democrats. Like other major
reforms of the past, however, it will entrench the private nature of the system,
and likely render national health insurance, or anything remotely like
“Canadian-style” health care, impossible to attain.
Antonia Maioni is an associate professor at McGill University