01/29/2014 09:20 EST | Updated 03/31/2014 05:59 EDT

Canadian Health Care: Separating Opinion From Fact

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.

When I 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!"

Separating fact 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

Although the Affordable Care Act 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 coinsurance of 30 percent or 50 percent 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 is implemented.

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 insurance.

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 percent 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."

On 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 AHCJ, 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.

  • 1. Finding a family doctor takes forever
    And then you end up on a wait list for two years.
  • 2. Specialists and hospitals don't talk
    Which means your specialist might send you to a hospital with a long wait time instead of one with a short one.
  • 3. Hospital parking is SO EXPENSIVE
    And nobody makes change inside.
  • 4. Doctors are too busy
    And it always feels like they're rushing you out the door.
  • 5. Friends with doctors in the family get better service
    They magically get appointments in two weeks instead of eight months.
  • 6. We have to pay for drugs/dentists/vision care
    But we always forget and end up forgoing care or emptying the wallet.
  • 7. And don't get us started on mental health coverage
    Which often isn't covered either.
  • 8. Family doctors insist you can't use walk-in clinics
    Because they lose money every time you do. Why is the pay structure like this again?
  • 9. Preventative care takes a backseat
    Even though it could help us save money.
  • 10. Moving provinces is a nightmare
    We're supposed to have universal health care, but good luck figuring out the paperwork to get reimbursed for out-of-province care.
  • 11. It costs money to get a sick note
    Why do we pay for you to scribble gibberish on a notepad? Feels like a hidden fee.
  • 12. And to renew prescriptions over the phone
    Now I'm going to the office for no good reason. But the doctor will get paid, so the system will lose money on the transaction. Genius!
    Even after the eHealth scandal in Ontario.
  • Seriously, do they just hate computers?
  • But even though things aren't perfect
  • At least we'll always be better than them
  • That is all