In 1999, I wrote my first book, Code Blue: Reviving Canada's Health Care System. In it, I noted Canada's obsession with all things American when it comes to debating health-care issues -- as if the only alternative to Canadian medicare was the American system. My point? Many countries offer sophisticated medical care and universal coverage and yet have very different health-care models. And, more importantly, several of these countries achieve better health outcomes.
In recent years, this problem has reappeared, but in reverse. Americans often talk about comparisons to Canadian health care as if our single-payer model is their only alternative.
Slate's Matthew Yglesias is the latest to offer up the Canadian system as a worthwhile comparison to the American model. To be fair, he actually writes that: "Now, there are, no doubt, downsides to [the Canadian] approach," an honest caveat that many American fans of Canada's system can't bring themselves to acknowledge. The hook for his piece was accurate, too. He wants readers to realize that if you compare public health care spending in the U.S. to public health spending in Canada, our Southern neighbours actually spend more per capita than we do. (That's over and above the billions that the United States spends on private care and private insurance.)
Speaking to his American audience, Yglesias's punchline is that when it comes to health reform, it's "insane to completely ignore the culturally similar neighboring country that spends less while covering more people." And if you put it that way, fine. Completely ignoring the Canadian comparison is foolish. But Yglesias' remarks repeat an implied mistake that others have made. When he talks about how Canada "covers more people" for less money, "covers more people" is a meaningless baseline without factoring for the scope, the speed and the quality of the care that coverage buys.
To get past the Canadian v. U.S. fixation, consider the following international health-care rankings.
- In 2010, the Commonwealth Fund ranked Canada 6th out of 7 countries in overall health care quality. The United States is 7th.
- In 2012, the Conference Board of Canada ranks Canada 10th out of 17 "peer states" on overall health care performance, using metrics that weigh heavily toward mortality rates. The U.S. is ranked 17th.
- In the one area where the U.S. scores consistently best -- publicly-funded access to drugs -- Canada scores very poorly in annual comparisons to other OECD countries, and one 2009 comparison ranks Canada between 22nd place and 29th place relative to OECD nations on various public drug access, public drug plan and reimbursement indicators.
- Another Commonwealth Fund review in late 2012 ranks both Canada and the U.S. poorly on a range of primary care measures. Canada is far back on the use of electronic medical records (just behind the U.S.); we finish 10th out of 10 on urgent access to primary care physicians, and 9th out of 10 (behind the U.S.) on after-hours access to a primary care physician.
And so on. There are other studies, of course, and they draw a similar conclusion.
I work in the Canadian system, and I'm often proud of what we can achieve for our patients. I've also worked with American health policy experts, and envy America's world-class research and the unchallenged leadership of institutions like the Cleveland Clinic, the Mayo Clinic and Johns Hopkins. Yet I've been a critic of both systems because I believe both countries can do so much better.
The first step to better health care? Breaking free from a pair of intellectual traps.
Trap 1: In both countries, the public debate remains fixated on "how many are covered at what cost." We should also be talking about what people are covered for, how and how well they're covered and overall wellness. We skip over these points because both of our (very different) health-care systems were designed around a 1940s and 1950s hospital-centric approach (a point I discuss in more detail in my second book, The Cure).
Trap 2: Too often we speak about "the best in the world" in a tone that suggests that Canadian health care (or American health care) is perfect, even though there are major problems both north and south of the 49th parallel.
To be fair, international health care rankings never offer a consensus on which country truly has "the best" system. But there is one area where these rankings are consistent: they usually place Canada and the U.S. mid to low pack.
We can learn more from a global health care perspective, and the tradeoffs each system makes. We pride ourselves on universality -- but so do the Dutch and the Swiss, and they don't have the sort of problems endemic to medicare (that is, long surgical wait times, diagnostic waits and limited coverage of drugs for rare disease patients).
There is no perfect health care system, of course. But there is world beyond North America. It's a point that writers like Yglesias should acknowledge and -- in an age of budgetary restraint -- governments across the continent should consider.