Yes, said Dr. Maurice McGregor, Cardiologist at the MUHC and founding member of Canadian Doctors for Medicare.
It is not pure chance that our two health care systems are so different. There are real differences between our values, our priorities and the role we see for the state in our affairs. After all we have developed our democracies in very different ways. In the US, through revolution and rejection of royal authority, in Canada through a process of slow evolution.
So it is not surprising that Canadians tend to look more to central authority to ensure the welfare of its citizens, while in the US rugged individualism and individual initiative get a higher rating. Both our economic systems are basically capitalist but Canadian capitalism is more regulated and has more socialistic tendencies. Indeed our health care system is almost completely socialist in its philosophy. “To each according to his needs”.
However, each country recognizes that the other has advantages, and it is ironic that at this moment there is a powerful lobby in the US advocating the Canadian system while in Canada we have a lobby advocating US type privatisation. Let us consider for a moment what each country might see as enviable in its neighbour’s system.
A major advantage of the Canadian system is its economy. In the 1970s when we launched Medicare Canada and the US spent the same proportion of our respective GDPs on health care, about 7%. Today, the US spends 5.5% more of its GDP on health care than we do and the gap is in creasing. Another advantage of our system is that coverage is universal, while over 47 million Americans have no coverage, and millions more have inadequate coverage. Viewed from Canada the most enviable feature of the US system is access, access to care when it is needed with no wait times (for those who can afford it).
Is there anything Canada should copy from the US system to improve our own, particularly with regard to wait time? Of course if we even fractionally copied their spending levels wait times could rapidly be abolished. But it doesn’t look as if this option will be open to us any time soon. So what else might we copy?
There is no question that market forces could bring benefits, but only to those Canadians who could afford to pay. However, at present any such benefits for those who could pay would only be realised at the expense of those who could not. Until we correct our current health manpower shortage, the private sector could only expand by hiring scarce manpower away from our public system, or even less desirably from third world countries.
But even if there were no manpower shortage, the hope that the profit motive would stimulate efficiency by minimizing costs and optimizing care is just hope, and is not supported by the evidence. For example, Woolhandler et al found in their 2005 US study that administrative costs in for-profit HMOs was 19%, compared to 13% in non-profit health care plans, (and 1% in Canadian Medicare) and in Devereaux’s 2004 meta analysis, services in investor-owned hospitals cost 19% more than in not-for-profit hospitals. Nor does the profit motive seem to result in better health outcomes. In two studies published in 2002, Devereaux and colleagues found higher risk-adjusted mortality rates in both for-profit hospitals and for-profit dialysis units. That they should cost more is not really surprising. Shareholder owned hospitals are meant to be profit maximisers, not cost minimisers, Also the profit motive gives private hospitals the incentive to attract relatively well, low-cost patients, and shunt the chronic expensive patients elsewhere.
However, for-profit healthcare has one enviable characteristic, and that is adaptability. The US type free market is able to react quickly to increased demand. For example, if the wait time for hip surgery is increasing, and a profit can be made, the equipment will be bought, the nurses and doctors will be obtained, and wait times will disappear, again for those who can pay.
In Canada by contrast, we have no financial incentive to respond to increased demand. Worse, we have a positive disincentive. If our hospital with its fixed budget performs 100 new expensive procedures, we go into the red and our CEO gets fired. So reacting to changing demand is extremely difficult in our system.
There is a partial cure for this. In most developed countries, including the US, fixed global hospital budgets have been abandoned, and some or all of the budget is determined by the number of medical acts performed. There are major disadvantages to this form of budgeting which I cannot discuss now, but some extension of this principle, at least for those services for which wait times are prolonged, could benefit our system.
Another advantage of the US system is that the private insurance model allows for greater emphasis on disease prevention. It actually pays for an American health plan like Kaiser Permanente to focus on prevention. By contrast , in Canada every health service including preventive health comes out of the budget. Consider one example. Until recently in Canada we had about the right number of gastroenterologists. Then the decision was made that we should screen almost the whole population every three to five years for colonic cancer. So suddenly we have a shortage of gastroenterologists. In the more flexible US system the gastroenterologist could hire and train sufficient nursing assistants to cope with the extra load under supervision. In our more rigid system, such adaptation to demand is extremely difficult. So there is much that we could copy from our neighbours to increase the adaptability of our system to change.
In conclusion, I believe that Canadians have developed the system that suits them best and they should certainly not allow it to be eroded by expanding US type, for-profit health care. But this does not mean that we have nothing to learn from our neighbours to the south.