In Critical Condition:
Health Care In America Canada's Way
What a universal health care
system delivers, good and bad
Barry Brown, Chronicle Foreign
Service, Thursday, October 14, 2004
Toronto -- Discovering he had colon cancer
came as a shock to John Kioussis, but after 10 days in the hospital,
attended by a battery of medical specialists, technicians, nurses
and other staff, his bill came to less than $85 in American dollars
-- and that was only for his phone and cable TV.
Under Canada's government-funded health
insurance system, Kioussis' care, from the first visit to a family
doctor, through visits to two specialists of his choice and his
hospital stay, was free, paid for by Ontario's publicly funded
universal health coverage.
"When you're sick like that and
off work, the last thing you want to worry about is how to pay
the bill," said Kioussis, 55. "I had excellent care
and one of the top specialists in the country, the same doctor
who would treat the prime minister."
That's the side of Canadian health care
familiar to many Americans -- a system that provides free cradle-to-grave
treatment to all, regardless of income or employment status.
The fact is, though, that Canada's system
is riddled with problems, many stemming from inadequate funding.
As a result, delays of several months are common before seeing
a specialist or getting nonemergency surgery.
For his part, Kioussis said the month
he waited between seeing his family doctor and his surgery did
not seem unreasonable. He admitted, though, that because of a
personal connection between his brother and the surgeon, the doctor
operated on him just before he left for vacation.
Although delays and other problems have
caused support to dip slightly, Canadians still overwhelmingly
back their universal health program. They think of their health
care system as a mark of their national identity, something that
separates them from Americans.
Meanwhile, a recent ABC News poll showed
that while Americans value the quality of U.S. health care, 62
percent think the nation should shift to a universal health insurance
program like Canada's.
As a result of the sharply differing
approaches Canada and the United States have taken toward financing
health care, their medical systems have developed in contrasting
The United States has more hospital beds
per person than Canada because most American hospitals are private,
while almost all Canadian hospitals are publicly funded. As a
result, American hospitals compete for patients, while Canadian
hospitals "don't fund excess capacity," said Sharon
Sholzberg-Gray, chief executive of the Canadian Healthcare Association.
By many measures, Canadians are healthier
than Americans, with a longer lifespan and lower infant mortality,
even though they spend much less on medical care. Canadians devote
about 10 percent of their gross domestic product, the total of
a nation's goods and services, to provide full health coverage
for all citizens. American health costs account for about 14 percent
of GDP, yet 45 million Americans have no health insurance and
many more have limited coverage.
One of the main culprits pushing up the
cost of care in the United States is the expense of administering
a plethora of complicated health plans. It has been estimated
that any large health insurer in a midsize U.S. state spends more
on administration than is spent on health administration in all
Dr. Catherine Kurosu is a gynecologist
at two San Diego hospitals. A Canadian, she said the biggest differences
between the two systems are that poorer Americans won't seek medical
care until their problems have become serious. In addition, she
said, American insurers often play games to avoid paying bills.
In San Diego, a lot of pregnant women
-- especially illegal immigrants -- show up with problems that
could have been avoided with prenatal care, she said. The idea
that they can't get this kind of care "still seems foreign
to me," she said.
"My patients are always interested
in finding out about the health care system when they find out
I'm Canadian," she continued.
When it comes to billing, the Canadian
system is a simple matter of sending an invoice to the Ministry
of Health, which pays on a fee-for-service basis, she explained.
In the United States, there are so many insurance companies, each
with its own rules covering not only the patient but also the
doctor -- as Kurosu learned when she had to wait months for an
insurance company to approve her.
U.S. health insurers nickel and dime
doctors by always sending bills back and questioning everything,
she said. "It's like a game to see how long they can forestall
Eleven years ago, Colleen Burns started
a medical imaging business in Buffalo, N.Y., right across the
border from Ontario. She expected 20 percent of her business would
come from Canadians willing to pay $300 to $600 in U.S. for quicker
access to high-tech diagnostics. Instead, the proportion is only
about 8 to 10 percent, she said.
Canadians need to feel a sense of urgency
and have the money before coming to the United States, "because
they can get an MRI for free in Canada," she said.
The health system is now itself in need
of emergency care in order to continue offering the benefits Canadians
have come to think of as their birthright, according to many experts.
Dr. Albert Schumacher, president of the
Canadian Medical Association, warns that shortfalls of cash and
medical staff have left the system unsustainable without major
Twenty years ago, Canada's federal government
unified the various health insurance programs run by the provinces.
Ottawa offered to pay 50 percent of the
programs' operating budgets, provided the provincial plans accepted
five basic principles, including nationwide acceptance of each
provincial plan, comprehensive coverage and no out-of-pocket costs
(co-payments or deductibles) for insured services.
"But since then, the federal share
has dropped to as low as 14 percent," said Schumacher, a
family physician from the border city of Windsor, Ontario.
In the 1990s, Canadian governments at
all levels began attacking their budget deficits with single-minded
intensity. With health care accounting for about 40 percent of
public sector spending, hospitals were closed, physician fees
were frozen or cut, nurses were laid off, and spaces for medical
students and medical technicians at government-funded universities
and colleges were cut back.
Along with a money crunch, Canada "has
a terrible shortage of physicians, " particularly specialists
and surgeons, a high proportion of whom are over 55 and ready
to retire, Schumacher said.
Fixing the health care system has become
a high priority for Canada's political leaders.
Last month, Prime Minister Paul Martin
made good on his main election promise to inject more cash into
provincial health programs and move to shorten waiting lists.
At a national health care summit, Martin
told provincial leaders Ottawa would ante up the equivalent of
an additional $34 billion in U.S. funds over 10 years to provincial
and territorial health programs, as well as an additional $3 billion
to ease wait times for hip replacement surgeries, cardiac and
cancer treatments. He also agreed to a plan for monitoring waiting
lists to determine the best method of reducing them.
As in the United States, the main problems
bedeviling Canada are the soaring cost of prescription drugs and
an aging population. Canada's provinces had called on Ottawa to
use its hefty budgetary surplus to launch a national drug plan
and leave to them the remaining health care costs, including home
care and services like psychiatry and chiropractics.
But during the summit, provincial leaders
abandoned that effort in exchange for more overall funding from
Sholzberg-Gray of the Canadian Healthcare
Association said another challenge plaguing the Canadian system
is the drain of doctors and nurses lured by higher pay and lower
taxes in the United States.
"There is also a circular effect,
because some doctors come back so they don't have to collect bills,"
On the issue of waiting lists for nonemergency
surgery, Sholzberg-Gray believes the federal government should
establish time limits for treatment.
One feature of Canada's health care system
is that if someone wants to bypass the public program and, for
example, pay a doctor to perform hip replacement surgery after
hours, he cannot. Because of fears that slipping the doctor a
little something extra could lead to the breakdown of the equal-
access-for-all principle, paying for insured services is illegal.
Those who believe that more private care
clinics would solve the problem of funding and shortages have
taken their case to Canada's Supreme Court in an effort to open
ODD MAN OUT
The United States is the only developed
nation without universal health care. Although health insurance
systems worldwide are straining as populations age, safety nets
have largely remained in place. Here are brief descriptions of
insurance systems of several nations..
Health care as percentage of GDP: 9.6
Health expenditure per person: $2,567
Universal care funded through mandatory
health insurance provided by Social Security, with private supplemental
coverage filling gaps..
Health care as percentage of GDP: 10.8
Health expenditure per person: $2,820
All individuals are enrolled in government-approved
health insurance plans partly financed by employer and employee
contributions, although high- income workers may buy private insurance
Health care as percentage of GDP: 8
Health expenditure per person: $2,131
A dual system in which workers enroll
in insurance programs through their jobs, while all others join
Japan's national health insurance plan..
Health care as percentage of GDP: 7.6
Health expenditure per person: $1,989
A publicly funded National Health Service
provides free care, with the option of private insurance for those
wanting treatment outside the state system..
Health care as percentage of GDP: 13.9
Health expenditure per person: $4,887
Federal and state governments pay most
of the cost of care for seniors and the poor, with employer or
individually financed insurance available for others. About 45
million people lack coverage.
Source: World Health Organization, Chronicle
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