Is Canada the Right Model for a Better U.S. Health Care System?
May 19, 2017
Knowledge@Wharton
For many critics of U.S. health care, the Canadian system of universal health
care has long been viewed as an alternative, superior model for the U.S. to
follow. Canadafs single-payer system is mostly publicly funded, while the U.S.
has a multi-payer, heavily private system. While dissatisfaction with the U.S.
health care system is widespread among Americans, Canadafs health care system
enjoys high levels of satisfaction among its own population.
Much of the appeal of the Canadian system comes from the fact that it seems
to do more for less. Canada provides universal access to health care for its
citizens, while nearly one in five non-elderly Americans is uninsured. In
Canada, coverage is not tied to your job or dependent on your income; rich and
poor are in the same system, and enjoy equal access. Yet last year, Canada spent
far less of its GDP on health care than did the U.S. — 10.4% compared with 17.8%
in the U.S. — which was the highest percentage of any nation in the world,
according to the World Health Organization. For all that, Canada scored better
than the U.S. on two commonly cited health outcome measures — infant mortality
and life expectancy.
What, if anything, can American policy makers and the public learn from
Canadafs success? Can some aspects of the Canadian system be applied to the U.S.
at a time when the American public remains deeply
divided about whether to replace and/or reform the Affordable Care Act?
eA Discombobulated, Fragmented Systemf
Why is the U.S. system so much more expensive? As Dan Polsky, executive
director of the University of Pennsylvaniafs Leonard Davis Institute of Health Economics,
notes, gWe have this discombobulated, fragmented system that leads us to have
very high administrative costs, and everything is disconnected. You have to go
from one system to another when you go from one provider to another. Some health
[information] gets lost with the transfer from one provider to the next. And
therefs a private health care system that funds you when you are under 65, and
when youfre over 65, you get funded by Medicare. And maybe most of your problems
occur when youfre on Medicare, so our private health care system doesnft have a
lot of incentive to keep you healthy when youfre over 65, because theyfre not on
the hook for it.h
gIn one sense, what Americans can learn from Canadians is nothing,
because we donft share the same views of society as they do.h –Mark
Pauly
Does that mean Americans have much to learn from Canada? Not necessarily. gIn
one sense, what Americans can learn from Canadians is nothing, because
we donft share the same views of society as they do,h says Mark Pauly, Wharton
professor of health care management. gThe design of a countryfs health care
system and the performance of it are very dependent on a specific countryfs
culture, ethnicity and a whole lot of factors that have nothing to do directly
with health care but have everything to do with health outcomes. Itfs the old
apples and oranges problem. Canada is most similar to us of any other country,
so in that sense we have more of a chance of learning some things. But the
literal answer to the question, eWhy donft we just copy the Canadians?f is
because we canft. Wefre not Canadian and we donft share the same history or the
same social ethos.fh
Polsky agrees that differing social values are the core issue. gAt the end of
the day, the debate is about what are our values. What is the best way we should
structure a system of insuring our public? When you talk with the Canadians,
there are a number of problems with their health care system that, for a lot of
people in Canada, reflects their values about being in a country that has a
system that provides c for all of its citizens. For the most part, they are very
much in favor of their health care system. In our country, we have a mix of
public and private insurance. Half of our health care is paid through Medicare
and Medicaid, which are publicly sponsored health care programs, and the other
half is paid through private insurance. What you end up with here is a very
mixed view of the values.h
Supporters of universal health care in the U.S. donft always understand the
difference between a esingle payerf system and universal health coverage.
Explains Polsky: gUniversal coverage is [when] everyone has some health
insurance. That would be my value; everyone is insured in some way. We could
achieve that in this country just by filling in the holes, with a little bit of
Medicare, a little bit of Medicaid, a little of employer coverage, and the
individual market. [It would be] a crazy, mixed-up system, and at least wefd
have everybody covered. A single payer system is what they have in Canada, which
is that in each of the provinces, all health care for hospitals and mostly for
doctors is paid for through the public insurance system. This is one system that
pays each doctor in each hospital.h
Still, gthere are some things we can learnh by studying the Canadian system,
Pauly argues. gNumber one, although in many ways the system looks like ours, the
system has a much greater emphasis on primary care and less emphasis on
specialist care and hospitalization, and on complex and costly procedures. And
that probably contributes a lot to the lower spending [in Canada], because while
primary care can be good for you, expensive procedures such as for cancer may
add only a few months of life but cost hundreds of thousands of dollars.h
Pauly adds, gOrdinary people in Canada are healthier than in the U.S., but
outcomes for cancer and very serious illnesses are less good there. Itfs a great
place to live as long as you donft get too sick, as one critic put it.h
Another fact that might dissuade Americans from duplicating the Canadian
model, Pauly adds, is that gCanadians have a longer waiting list for things like
joint replacement, so if your hips are killing you in Canada, you may wait
months for that [surgery] to happen. In the U.S., the orthopedic surgeons are
calling you every day, wondering when you are going to come in for your joint
replacement procedure. We probably do too many; they probably do too few. But
the safety valve for Canada is that they can always come across the border, and
have a procedure done here.hf
Why Canadafs System Developed Differently
Given cultural similarities between U.S. and Canadian societies, why did
health care in Canada emerge so differently? gIt may have something to do with
the respective ages of the countries, time of settlement and who settled there,h
asserts Michael Decter, a former deputy minister of health for Ontario who was
responsible for managing that provincefs $18 billion health system, serving its
11 million residents. gWhen Saskatchewan — one poor province — started the ball
rolling in the 1950s by providing its people with hospital insurance, its
government said they were going to pay the hospital bills for all of their
citizens. And then a decade later, they said theyfd pay the physician bills,
which was much more contentious. A lot of your northern [U.S.] states were not
far off that. Wisconsin, Minnesota were heading that way.h
gAt the end of the day, the debate is about what are our values. What is
the best way we should structure a system of insuring our public?h –Dan Polsky
The major difference from the United States, adds Decter, is that gthe U.S.
already had a fairly well developed health insurance industry, and Canada
didnft. So, when Canadian [provincial] governments got into the act in terms of
paying for services, they werenft displacing big, for-profit insurance
corporations. They were, at most, displacing some voluntary Blue Cross health
organizations. In some provinces, the physicians themselves operated some
schemes of pre-paid insurance.h
That doesnft mean that everyone in Canada is equally delighted with the
Canadian system, Decter notes. gIn Canada there is a small minority that would
like us to go in the U.S. direction. There is litigation around that, because
the government, in paying for health services, sort of gave itself a monopoly. A
doctor canft say, eIfll take the government fee for poor people but Ifd like to
bill a wealthy guy a lot more to do his hip,f [for example]. If youfre in the
government scheme, itfs one price.h
In comparing the health care systems in the U.S., Canada and the U.K., many
people gsee the National Health Service (NHS) in the U.K. as similar to
Canadafs, but we [in Canada] have a lot more similarities to the U.S.,
actually,h Decter says. gMedicare [in the U.S.], which clicks in at 65, is more
comprehensive than Canadian Medicare; it pays for a lot of services that we
donft pay for. Medicare uses more of the model we [use]: It pays providers, but
they donft work for it. The [British] NHS is different, in that it employs a
million people, who are actually employees of the NHS. In Canada, we left the
hospitals as free-standingc. They get most of their money from the governments,
but the governments donft run them. The governments set policy, but the
hospitals have a degree of independence. They decide whom to hire. They
negotiate with their own unions, and hire their own medical staffs.h
The Canadian system has its origins in cost-sharing, Decter adds. gSome
provinces started to pay their hospitals, and the federal governments said, eWe
want this to be a national plan, and a fair plan, so wefll pay half of the
hospital cost for every province if they provide the insurance.f And then they
did the same with doctors. But it was costing too much, so they capped their
payments. And therefs been a whole history of arguing over that. But the dynamic
that is now going on with the Affordable Care Act — where youfve got [state]
governors in the act, and therefs a back-and-forth about who should be covered,
[and about] where the poverty line should be set — we donft have that. But we do
have the tension between the national government and the provinces over
funding.h
Thus, notes Decter, gThe provinces would like the national governments to
give them more money for health care, and they fight about it. Theyfre just
coming off a 10-year agreement where the federal government said it will
increase its contribution by 6% a year. That made some sense in 2004, when it
was agreed to. But now, with much slower growth and less inflation, it seemed
overly generous, so the federal government has cut that growth to 3% a year, and
added some additional money for home care.h
Unnecessary expenses
Despite its relative low costs, the Canadian health care system is not free
of wasteful practices. An April
2017 report by the Canadian Institute for Health Information (CIHI) and
Choosing Wisely Canada (CWC), a nationwide clinician-led campaign that develops
recommendations about tests and procedures, found that up to 30% of tests and
procedures in Canada are potentially unnecessary, waste health-system resources
and increase wait times for patients in need. Highlights from the report
include:
- Almost one in three low-risk patients with minor head trauma in Ontario
and Alberta underwent a head scan in an emergency department, despite CWCfs
recommendation that this is unnecessary and potentially harmful.
- One in 10 seniors in Canada use a benzodiazepine on a regular basis to
treat insomnia, agitation or delirium. Several recommendations by CWC have
highlighted the harms of long-term use of these medications.
- In Ontario, Saskatchewan and Alberta, 18% to 35% of patients undergoing
low-risk surgery had a preoperative test, such as a chest X-ray, ECG or
cardiac stress test. Such tests are unnecessary, potentially harmful and can
delay surgery, the report notes.
- For children and youth in Manitoba, Saskatchewan and British Columbia,
rates of low-dose quetiapine (likely used to treat insomnia) increased
rapidly, although the use of this medication in children and youth to treat
insomnia is not recommended by CWC.
gIn Canada there is a small minority that would like us to go in the U.S.
direction. There is litigation around that, because the government, in paying
for health services, sort of gave itself a monopoly.h –Michael
Decter
Building a Single-payer System
Despite such imperfections, there is growing support in the U.S. for
instituting a single-payer health care system based on the Canadian model. But
it is far from certain that there is enough of a social and political consensus
to bring it about. Notes Pauly, gThere has been more of a consciousness
[lately], and probably consensus on what ought to be some social objectives here
[in the U.S.] What I donft see, though, is a consensus on how to achieve them.
[U.S. Senator] Bernie Sanders believes, I guess, that you should have a right to
as much health care as you and your doctor agree on, and it should be paid for
by millionaires and billionaires. But I donft think we really have a national
consensus on thatc The real question is eHow much health care does an individual
person have a right to; and who has the obligation to pay for it? And who should
pay for that?f Those questions are not addressed by Sanders in a way that there
would be a consensus on.h
Whatfs the most practical way of bringing to life Sandersf dream of a
single-payer, national health care system in the U.S.? Perhaps, argues
Pauly, by gletting it happen piecemeal, state by state, just as it happened
piecemeal, province by province in Canada. Although there was an overarching
federal plan there to get the individual provinces to coordinate and subsidize
them, originally it was a provincial initiative. Maybe thatfs the way that
Senator Sanders ought to go. First, start back home — and see if he can get
Vermont to do what he advocates for the rest of the country. And then New
Hampshire should be easy and then work across the northern tier. Washington
[State] should be a snap, rather than try to persuade the heart of Republican
power in the South to go along with this; thatfs never going to happen.h
For his part, Polsky argues, gItfs one thing to talk about the values that
are consistent with the health system you want; itfs another thing to get
there.h Sandersf plan has resonated with many in terms of the values it
embodies, he notes, gbut the details of that plan have never been worked outc.
And a lot of the challenges are in the details.h