With every health-care reform debate in America, it’s only a matter of time before politicians and pundits start to point north to Canada, as either a beacon or boogeyman.
As a family physician working in Toronto’s inner city, my practice runs the spectrum from the homeless, to the working poor, to those solidly in the middle-class and the finance industry. With that said, it’s always a shock to see how our health-care system is frequently mischaracterized and maligned in U.S. discourse. With support for single payer on the rise in the United States, and Senator Bernie Sanders’s increasing focus on Canada, it’s worth a close-up of the health-care system I work in, warts and all.
Medicare—the colloquial name Canadians also use for our single-payer health-care system—is a partnership between the federal government and Canada’s 13 provinces and territories. Both levels of government share responsibility for funding, but the provinces and territories are responsible for program administration and ensuring that care is available in their respective jurisdictions. This allows for regional variations, while also granting power to the federal government to tie its share of funding to common national goals. The legislative framework that sets the base conditions for this partnership is the “Canada Health Act.” Importantly, the conditions that provinces and territories must meet to receive their share of federal funds under the Canada Health Act are also the ones that ensure the integrity and principles of single payer in each province. For example, physicians cannot charge patients for services already funded by the public purse, and insurance companies cannot sell duplicative insurance for services already funded by Medicare.
This stands in contrast to the proposed funding framework in Senator Sanders’s “Medicare For All” plan. Though details are vague concerning what level of government will be responsible for funding Sanders’s plan, the legislation largely implies a national system. This avoids the messiness that often unfolds in negotiations with states or, in our case, provinces. However, as others have pointed out, this might mean significant opposition from those states with a political culture that has a dim view of federal partnership (and government itself). The Affordable Care Act’s attempt at expanding state-based Medicaid serves as a cogent example.
Though Canada is often described as having a “socialized” system, this is in fact one of many mischaracterizations. Doctors in Canada are rarely government employees. Rather, we maintain our autonomy as private practitioners, while drawing our income from the public insurer. In this sense, we largely work as independent contractors. Our interactions with “government bureaucrats” are few and far between. Where I practice, we employ only two billing clerks for over 70 physicians. That’s typical for Canadian doctors, and in sharp contrast to our U.S peers. Rather than billing a single payer as I do, an American physician might have to deal with Medicare, Medicaid, Blue Cross Blue Shield, and Aetna, each with their own billing practices and bureaucracy, requiring multiple billing staff per doctor. This is unimaginable to Canadian doctors. In comparisons of administrative costs between the United States and Canada, the average cost for billing and overhead in U.S. private insurance plans is 18 percent, whereas overhead in Canada’s single-payer public insurance plans amounts to a mere 1.3 percent. Another study showed U.S. physicians spend nearly four times as much money interacting with insurance payers than do their counterparts in Canada.
For Americans looking north to what Canadian Medicare has to offer, perhaps the most compelling perspective is that of our patients. Single payer in Canada covers all medically necessary care that occurs inside a hospital or is provided by a doctor. When patients arrive, whether to a clinic for a check-up or to the hospital for surgery, they present their health card from their provincially administered public insurance plan, and receive care with no out-of-pocket payments or complicated insurance forms. This is true for primary care, emergency department visits or complex cancer care. For my patients, many who struggle to make ends meet, even a small copay would be enough to deter routine care for cancer screening or preventative health checks for diabetes. In fact, some of the best research done on the inherent issues related to copayments comes from U.S. researchers.
However, there are some important gaps that make Canadian Medicare less universal than it should be. The problem lies in how we’ve historically defined universality with respect to medically necessary care. Important outpatient services, like prescription drugs and dental care, are not included, and thus not covered under the provincial single-payer plans. Instead, this subset of services, much like the existing structure for U.S. health care, is paid for by a complicated mix of public and private payers. For these services, Canadians rely on job-linked health benefits, out-of-pocket payments or a patchwork of means or age-tested public plans that vary by province. As a result, one in five Canadian families say they are unable to fill prescriptions due to cost, and roughly half of Canadians who lack dental insurance avoid going to the dentist at all.
This is one of the starkest differences between the U.S. campaign for “Medicare for All” and Canadian Medicare. Senator Sanders’s plan is much more comprehensive and includes “essential health benefits” that Canada does not yet cover, like dental care and prescription drugs. One well-known Canadian columnist has even declared that “Bernie Sanders’ Medicare-for-all plans should leave Canadians drooling with envy.”
Despite the enthusiasm, even some of the most ardent supporters of “Medicare for All” may concede that the chances of this bill’s passage, any time in the near future, are slim at best. Nonetheless, it comes at a time when support for U.S. single payer is on the rise. So much so that Senators like Elizabeth Warren, Kamala Harris, and Corey Booker, all touted as possible Democratic presidential nominees, are co-sponsors of the Sanders bill.
Of course, no health-care system is perfect and it’s, therefore, not surprising that Canada is no exception. While Canadians consistently report high satisfaction with care, we wait longer than we should for elective procedures. The operative word is “elective.” For emergency cases, time from diagnosis to treatment is measured in minutes and hours. For less urgent cases, care is provided in days, not weeks. It is only with some elective cases that patients may wait. The zombie idea that Canadians die while on wait lists is simply false, no matter how often it’s repeated by opponents of single payer.
Elective waits are obviously a problem in need of a solution. Yet it’s essential to keep in mind that the root of these waits doesn’t stem from the way we finance care through each provincial single payers. Rather, waits come from the way health-care services are delivered. In Ontario, the number of seniors is expected to double by 2037. Yet our system’s organizing unit is still, by and large, the hospital. As people age, the burden of disease shifts from acute to chronic disease, like diabetes and hypertension. In hospitals, these chronic conditions are expensive to treat and tie up resources that could be redirected elsewhere. Instead, higher quality and more cost-effective chronic care should be delivered in primary care clinics, along with investments in preventative care and population health. Health sector leaders are beginning this transition from acute to community care settings, but more needs to be done, and at a brisker pace.
We also need to do a better job of spreading and scaling innovations. Every day, there are doctors, nurses, administrators, and others implementing innovative solutions to respond to changing circumstances. For example, an Ontario eConsult project built around virtual access to specialists reduced the need for in-person consultations by 40 percent, with specialist advice arriving, on average, in just two days. Using an interdisciplinary team approach, advanced practice physiotherapists and centralized intake systems, the Alberta Bone and Joint Institute reduced elective or non-urgent waits for hip and knee surgery from eleven months to nine weeks. But as a system, we need to do better to ensure these best practices are spread from coast-to-coast. This is the transformation with which many health-care leaders in Canada are currently grappling.
Ironically for American readers, there are areas where Canada’s health-care system underperforms on equity, as well. Yet this is not because of inequitable access to hospital and physician care, as is so common in the United States, but rather largely due to the gaps in our universal system for prescription drugs and dental care. Though for every dollar spent on health care Canada spends much more publicly than the United States (73 percent vs 51 percent), we’re far behind many of our international peers. For example, for every dollar spent on health care in the UK, 80 percent comes from the public purse. In Sweden, its 83 percent, and in Germany 85 percent. These European systems also provide public funding for a broader range of services than does Canada. For example, Canada is the only high-income country with a universal health-care system that does not include a universal drug plan. It’s an area many, including Canadian Doctors for Medicare, are working hard to change.
It’s an important reminder that our common problem isn’t primarily too much public funding. In fact, it’s just the opposite. Though the degrees and form of Canada’s challenges are markedly different from the United States, the Medicare For All agenda offers inspiration for Americans and Canadian alike.