Comparing U.S., Canadian health-care systems
By Trudy Lieberman EvidenceNetwork.caFeatures Clinical Patient Care
Feb. 3, 2014 — One thing Americans and Canadians can agree on is that we don’t want each other's health-care systems. In truth, most Americans don’t know how Canada’s system works and Canadians don’t know much about the U.S. system.
What Americans know has come mainly from the negative talking points of
politicians and others who have argued for years against national health
insurance. Two decades ago, The New York Times reported that Canadian
women had to wait for Pap smears, a point vigorously refuted by the
Canadian ambassador who shot back in a letter to the Times editor: "You,
and Americans generally, are free to decide whatever health-care system
to choose, avoid or adapt, but the choice is not assisted by opinions
unrelated to fact."
Yes, there are waiting lists for some
services — but, no, Canadians are not coming across the border in droves
to get American care.
There’s misinformation among Canadians, too.
Wherever I went, Canadians told me they thought, mostly based on what
they said they heard on CNN and Fox, that Obamacare meant America was
getting universal health coverage like their country has.
explained the law was simply another patch on a patchwork quilt of
coverage, and the Congressional Budget Office had estimated last year
there would still be some 30 million people without insurance, the
reaction was "the news media didn’t tell us that." A former deputy
health minister in New Brunswick said to me, "After all that, you will
still have 30 million people without coverage!"
from opinion as the Canadian ambassador long ago urged was something I
tried to do as I made my way across Canada while visiting there
recently. In some ways, the Canadian system is very different from U.S.
health care. In other ways, it’s very much the same and faces similar
challenges in the years ahead.
What we don’t share
the Affordable Care Act (ACA) in the U.S. calls for more people to have
health insurance by offering subsidies and mandating all Americans have
it or face penalties, the concept of universality is still a far distant
goal. The Canada Health Act, on the other hand, calls for universality
— all residents must be covered by the public insurance plan run by
their province on uniform terms and conditions. They have coverage
wherever they are treated in their home province, and there’s none of
this stuff about limiting the doctors and hospitals that patients can
use as a condition of getting full benefits. In Canada, there are no
financial barriers to care at the point of service as there are and will
continue to be in the U.S.
Canadians don’t pay co-insurance of
30 per cent or 50 per cent if they have an outpatient procedure or go to
an urgent care clinic, charges that are becoming increasingly common
here. They don’t worry about paying a gigantic bill if they happen to
use an out-of-network doctor or hospital. The publicly funded system
north of the border bases patients' access to medical services on need,
not on the ability to pay. To use the word "ration," Canadians ration by
need; Americans ration by price and will continue to do so as the ACA
Because it’s publicly funded, Canadian health
care is more equitable. There’s no such thing as buying a platinum plan
and getting first-rate coverage or a cheapo bronze policy and paying 60
per cent of the bill yourself. The tiered policies available in the
state exchanges further bake inequality into the U.S. system. People
have wildly varying benefits depending on where they live, how old they
are, where they work and how much they can afford to spend on health
That's not the case in Canada, except when it comes to
prescription drug coverage. Drug benefits are quite unequal in Canada,
and the lack of them is a pretty big hole for about 10 per cent of the
population. There is no universal drug benefit, although two provinces
have mandatory drug insurance — you can get it from an employer or buy
it from a public plan. About 40 per cent of the population gets coverage
from their employers. If you can’t afford the premium, there are
subsidies. In that sense, Canadian drug coverage in those provinces
resembles Obamacare. Still, having drug benefits does not necessarily
mean adequate coverage, says Globe and Mail health columnist, André
Picard: "The big difference from the rest of Canada’s system is there is
very little first-dollar coverage of prescription drugs."
this trip I heard much more about the social determinants of health than
I hear in the U.S. Almost everyone I interviewed mentioned the dismal
health stats for aboriginal populations and the need to improve access
and quality of care. I tried to remember the last time I heard anyone
discuss the medical problems of Native Americans or quality of care
provided by the Indian Health Service.
I asked Michael Decter, a
health policy expert and a former deputy health minister in Ontario,
what was his wish list for Canadian health care. Topping his list was
not more money for the health system; it was more for education aimed at
improving the lives of aboriginal peoples. Better education correlates
with better health. The second was drug coverage. Canada’s infamous
waiting times were not high on his list of priorities. In fact, he
didn’t even mention them as a problem.
Trudy Lieberman, a former
president of the Association of Health Care Journalists, is a contributing editor to the Columbia Journalism
Review. She is a fellow at the Center for Advancing Health where she
blogs about paying for health care.
Published with permission of the Association of Health Care Journalists.
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