Leslie Sexton

Wednesday, September 8, 2004

Does the United States Have a Better Health Care System Than Canada?

Yes Side

“In the one, the private, the aim is to achieve the highest level of care with the understanding that some will not participate in the system; in the other system, quality is sacrificed for the sake of ensuring that all have access to care…America will put the best technology in every doctor’s office, whereas Canada will make do without the latest technology in order that all can get into a doctor’s office.”

SUMMARY

-Medicare in Canada leaves Canadians waiting too long for care, there is a lack of hospital beds, and there is not enough of up-to-date technology

-public opinion polls suggest there is a concern

-“it seems that Medicare is a fine system as long as you don’t have to use it”

-in America, there is prompt, high quality care

-universal health care coverage sacrifices quality of care

-it is arguable whether these sacrifices are worthwhile or not

-a health care system must offer everyone in the system the best chance for survival

-Gladwell argues that “one of the principal functions of a health care system is to offer all of those in the system the greatest possible chance of survival in the event of some extraordinary occurrence”

-in many extraordinary occurrences in Canada, people get “Third World care”

-Gladwell acknowledges that a rich person would get better health care than the poor, since there are several tiers of care

-the benefit is for upper middle class America, where cost is not an object, and they get the highest quality of health care available

-these people demand high quality care, and only an American system has the market to deliver

-this part of the system is valuable because there is innovation, doctors get better training, and resources are available in case of extraordinary events

-for example, in 1984, there were about five CAT scans in Ontario, while in the USA, some individual hospitals had five CAT scans

-Gladwell makes the point that “both systems mean different things to different people in different stages of their lives”, for example, in terms of gender:

• women use the system chronically, going to the doctor every few months, yet they only need ‘low tech’ health care, like a pap smear or a breast exam
• patterns of mortality and morbidity show that there are many more potential problems for a woman’s health that a man’s at the age of thirty
• men, however, use the system acutely (many men in their thirties and forties do not visit the doctor unless there is something seriously wrong)
• the health problems that men have usually hit them well into middle age
• up until their sixties, men typically die because of shootings, car accidents, etc., while women typically die from cancer or diseases
• the ideal health care system for a man is acutely oriented, and is high-end and specialized, to deal with serious problems immediately (essentially, an American system)
• a woman’s ideal health care system is chronically oriented, sacrificing quality for the ‘presence’ of a doctor (essentially, a Canadian system)
• for example, men need liver transplants (which are high-end, expensive, and complex treatments) much more than women, since women aren’t drinking as much

-therefore, according to Gladwell, “this whole debate about what is better, the American system or the Canadian system, is essentially a variant on the gender war”

-in Canada, trauma care lags far behind America

-the American system does not just work for rich men, because men typically don’t need these expensive health care procedures until they are middle-aged

-the Americans who are not insured are typically young, while the elderly are insured under Medicare

-young men can also get care form charity hospitals

-hospitals are non-profit by law in America because they need to provide charity care to those who cannot afford it

-people in Canada, as well as any system similar to it have approval ratings of the system over 90%, but these numbers fall when asked about the quality of care

-in America, people hate the system, but there are high approval ratings for the quality of care

-mortality figures show that Canadians live a bit longer, but the greater issue is morbidity, which is lower in America

-for example, in America, someone with blocked arteries can get a bypass quickly and can go back to what he was doing before, while a Canadian would be less likely to get a bypass

-comparing Toronto and Washington, D.C., two metro areas the same size:

• there is one team of cardiac surgeons in Toronto that perform most of the bypass surgeries
• in Washington, there are about six, and the number of bypasses done is many multiple of those done in Toronto

-low morbidity does not extend life, it improves it, therefore in the U.S., someone who get the necessary treatment and suffer less

-Gopnik argues that health care, like a nationalized system of pensions for the elderly, is an anxiety that is felt at a universal level in society, so a universal and national system is built, accepting the problems that come with it, because the principle can resolve the anxiety

-however, in Canada, where there are continuous arguments about health care funding, it is clear that the anxiety has not been resolved, it has simply been shifted

-in the United States, anyone out of a job qualifies for Medicaid, and the elderly receive Medicare

-these are the two most vulnerable groups in society

-the middle and the upper classes are now under a ‘maximally flexible system’

-most medical progress and innovation have come from the U.S. in the past twenty-five years

-the American system pumps money into research, and their free market system is ‘incredibly dynamic and innovative’

-countries with a universal system use this innovation and new technology to improve their health care

-there is a difference between cutting-edge medicine and ‘heroic medicine’

-“The American system shifts costs from businesses and families on to the health care system. The Canadian system does the opposite.” For example:

• if a woman needs a hysterectomy in the United States, innovations have developed a laparoscopic surgery with a laser
• it is initially expensive to buy the laser and train doctors to use it, but it means the woman only stays at the hospital a day, she can go home, work, or take care of her children
• the Canadian system uses a traditional hysterectomy, which costs less, but the woman must stay at the hospital for two weeks, inconveniencing the family and the employer, resulting in further crowding of the system

-Gopnik brings up the problem of a premature baby being born, requiring months of intensive care, which in America would result in bills running up to hundreds of thousands of dollars, where in Canada or France, the family does not have to worry about how much it will cost, or when the insurance runs out

-Gladwell argues that this philosophical question can be resolved technically

-if a family has health insurance that runs out when they have a premature baby, they have the wrong health insurance

-women who are at high risk of having a premature baby should buy health insurance policies that cover them for an unlimited amount of time if they do have a premature baby

-Gopnik’s example is not a fault in the system; it means people are not educated about the need for appropriate insurance

-the situation can be improved without changing the system, for example, Congress can pass a law forcing all health insurance policies covering obstetrical care to include an unlimited component for premature babies

-medicine and health care is probably going to change more in the next fifteen years than in the last hundred

-for example, drugs will become more important than previously, as diseases will be transferred from the surgeon to the pharmacist

-single-payer systems are extremely inflexible (the Canadian system was slow to catch up with the change in the last twenty years)

-the American system is “the most flexible, the most willing to deal with these changes, the quickest to adapt to them, the most innovative”

-social engineering will only compromise the flexibility of the system at a time when flexibility is important

-Gladwell favours “a system that is, for all its faults, incredibly dynamic” while Gopnik favours “a system that, for all its faults, is incredibly good at delivering the status quo”

GLOSSARY

Medicare (Canada): The unofficial name for Canada’s government monopolized public health insurance system. (See Canadian Health Care system for full description.)

Medicare (U.S.): A program under the U.S. Social Security Administration which reimburses physicians and hospitals for health care given to people over the age of sixty-five

Medicaid: A program in the United States that reimburses hospitals and physicians for providing health care to qualifying people who are unable to finance their own medical expenses. It is funded by both the states and the federal government.

Mortality: Death rate.

Morbidity: Amount of disease; level of suffering.

Chronic Health Care: Care lasting for a long period of time and reoccurring frequently

Acute Health Care: Care needed for acute patients, afflicted by a disease that strikes quickly and causing severe damage to the patient’s health.

Heroic Medicine: Traditionally, this has been defined as aggressive medical practices or methods of treatment. In this article, heroic medicine is used to describe possibly unnecessary treatment to keep people alive by heroic measures that are hard to justify it terms of cost.

Single Payer/Egalitarian/Universal System: Used in this article to describe the Canadian health care system.

Free Market System: Used in this article to describe the American health care system.

Canadian Health Care System: Canada has the world’s most fully socialized health care system. Under the Canada Health Act, all Canadian citizens are guaranteed access to free health care. Under the Canadian Constitution, health care is a provincial responsibility, yet the Canada Health Act provides for federal transfer money to the provinces, provided that the provinces keep health care accessibly, universal, comprehensive, and publicly administrated. Provinces provide all Canadians with health cards, entitling them to free medical care for almost all procedures.

American Health Care System: The American health care system is a free market system. Health insurance must be paid for privately. The only government-funded aspects of the system are Medicare and Medicaid (see above).

Two-Tier Health Care: Two-tier health care is the system adopted in the majority of developed countries. Under this system, the private sector and the government-funded public system operate in parallel. There are two tiers of care, one for the majority of the population, the other for the wealthy, who can afford better care. The private system offers better treatment, shorter waiting times, but is more expensive. Supporters of the two-tier system argue that it will introduce more flexibility into the system, reduce waiting lists, and compete with the public sector to make it more efficient. Two-tier health care is the status quo in Europe.

PROBLEMS WITH THE SOCIALIST SYSTEM

-the Canadian health care system is socialist, as there is a government monopoly on health care services

-the biggest problem with the socialist system is that it is very idealistic

-in reality, supply never meets demand

-government monopolies are very inefficient, for example, within four years of the Bolshevik revolution, Soviet production had fallen to 14 percent of its levels before the revolution

-the system is inefficient, because there is no competition

-without competition, inept, mismanaged, or inefficient organizations are allowed to survive, where, under a free market system, they would be forced by consumers to offer a competitive service, or be filtered out by the system

-in the Soviet Union, there was a massive shortage of goods, which were usually of poor quality; for example, people had to line up to buy food

-under a free market system, people would recognize that there is an opportunity to make money in this trade, there would be investment, and the new providers of the service would compete with the government-controlled sector, improving the overall quality of the service

-however, these opportunities are eliminated under a socialist system

-the same can be said for health care, since Canada does not have enough health care services to support our population

-under the Canada Health Act, no private sector can move in to compete with the public sector, therefore the overall quality of health care does not increase, and supply does not meet demand, as we can see by waiting times in Canada

-like in the Soviet Union, where every citizen was equal in a classless society, yet everyone was living in poverty, everyone is equal under the Canadian health care system, yet everyone is also reduced to a lower standard of health care

ALTERNATIVE SYSTEMS

-compared to the health care systems in most other developed countries, Canadian and American health care systems are opposite extremes

-most developed countries have some form of two-tier system

-Australia

• the national government funds health care, and the states, with financial assistance, fund and administer public hospitals mental health services and community health services, and regulate health workers
• there is a large private hospital sector, and use of it is voluntary, but encouraged by the government
• public health care provides care for those who cannot afford it, and is financed through general taxation
• to promote use of the private sector, subsidies are offered to users of the private sector, and there is a surcharge on Medicare for families earning over a certain amount of money who use the public sector
• in March 2001, about 45% of the population had additional private health insurance
• significant problems with the system include a lack of dental coverage, shortages of doctors in some areas, geographical and cultural barriers to health services, and differentials in health status between Indigenous people and other Australians

-Denmark

• this system is financed through local taxation, and by funding and provision of health care at the county level
• hospital care is mainly provided by hospitals run by the state, private hospitals account for less than 1% of hospital beds
• all Danish residents use the statutory health care system, but voluntary health insurance, which is negotiated mostly in job contracts, has developed in the past two years because of waiting times, etc. However, it is mostly young people who have this coverage, and there is limited capacity in the private sector, so this policy has not been put to much use so far. About 28% of the population have some form of this coverage.
• there are not many benefits provided by the statutory health care system, for example, certain types of treatment must be considered useful by a doctor to be funded publicly user fees are only applied to physiotherapy, dental care and optometry
• a waiting time guarantee of two months took effect July 2002
• Denmark is also facing the problem of an ageing population

-France

• the French health care system is funded mostly through taxation and social health insurance contributions from employers and employees
• health insurance schemes and the government pay for health care, and it is provided by private practitioners as well as public and private hospitals
• the French have free choice of doctor and hospital
• all residents of France are covered by public health insurance; there are three main health insurance schemes that cover most of the population, and residents are covered by a specific plan based on their professional status and place of residence
• about 86% of the population is covered by voluntary health insurance
• France has many problems with its health care system, however; dissatisfaction among doctors and health care professionals, a possible shortage of doctors as a result of quotas imposed in medical schools, an ageing population, and growing costs of public health care

-Germany

• health care system is funded mostly through social health insurance contributions
• ambulatory care is delivered by physicians who are paid fee-for-service
• hospitals deliver care through public and private providers
• 88% of the population is covered by statutory health insurance, and 9% are covered by private insurance
• all people in “gainful employment” must be insured under statutory health insurance

-the Netherlands

• there are three main elements of Dutch health care: public universal insurance for “exceptional medical expenses” (long-stay are, mental health, etc.), social health insurance for people with low incomes and voluntary private health insurance for people with high incomes, and voluntary supplementary insurance open to everyone
• people who receive social security benefits and people over the age of sixty-five are insured under the Sickness Funds Act
• the biggest problem is waiting times

-New Zealand

• health care is delivered by public and private providers
• the health care system is financed by taxation, and covers everyone in the country
• access to public hospitals are free, but most people pay for some primary care and pharmaceuticals
• low-income patients, children, and high users of services are subsidized
• private insurance is voluntary
• there has been a great deal of restructuring of New Zealand’s health care system
• problems that still exist are inequity of access, a lack of citizen participation in the decision-making, and quality of care is a current priority

-Sweden

• the country councils are responsible for health and social care, while the municipalities are responsible for long-term care

• the system is mostly funded by county council taxes, and supplemented by grants from the national government
• hospitals are publicly owned, but have independent status
• the Swedish national health service provides coverage to all residents
• no private coverage can be substituted, but a small percentage of the population possesses supplementary voluntary insurance
• waiting times are the biggest problem of the system, and this is usually associated with a shortage of health care professionals

-the United Kingdom

• health care is funded mostly through national taxation
• hospitals are mainly publicly owned
• private hospitals provide health care to privately insured patients, or patients who will pay directly
• all residents of the United Kingdom are entitled to coverage under the UK National Health Service
• 11.5% of the population have supplementary private medical insurance
• health care in the United Kingdom is said to be under funded, resulting in long waiting lists and poor quality hospital buildings

STATISTICS

-in 2002, life expectancy was 79.35 years in Canada, 76.8 years in America, 78.05 in the U.K., 81.5 in Japan, 79.8 in Italy, 79.25 in France, and 77.7 in Germany (OECD Health Data 2003)

-overall, the number of Canadians that were unable to receive treatment because of long waiting lists is very close to the number of uninsured Americans (Wikipedia)

-the article claims that there are 43 million uninsured Americans (about 16% of the population), yet other sources put this number at anything from 45 million to 41 million. A statistic with a range of four million cannot be very accurate. Furthermore, these estimates count every time a person is without health care during a year. For example, if a person changes jobs and is without coverage for two weeks, they are counted as one person without health care coverage. Someone could even be counted twice if they experience this situation more than one in a year. This figure is mostly likely closer to 20 million. This statistics even includes rich Americans who have made the conscious decision not to purchase health insurance, since they are able to afford high-quality health care if they are in need of it. The remaining Americans are mostly young adults who are earning entry-level salaries and are less likely to be sick than older Americans, who are able to afford health coverage.

DISCUSSION QUESTIONS

1. Gladwell says that “one of the principal functions of a health care system is to offer all of those in the system the greatest possible chance of survival in the event of some extraordinary occurrence.” In your opinion, has the American system achieved this? Has the Canadian system achieved this?

2. Do you think the American health care system is necessary for innovation and technological advancement in the medical world? Can these innovations still exist under any other system?

3. Do you place greater importance on universal accessibility than quality of care?

4. Do you accept Gladwell’s analysis of the “gender war” on health care?

5. Do you, like Gladwell, put a greater value on morbidity than mortality figures?

6. Gopnik argues that a universal system cures the anxieties of the public, despite the inequities and anomalies of the system. Do you think there is more anxiety felt about paying for health care in America, or the quality of care in Canada?

7. The only government contributions to health insurance are Medicaid and Medicare. Should these programs be expanded to include all Americans without health insurance? To what extent can they be expanded until the American system is no longer a free market system?

8. The American system demands more responsibility of the American public to lead a healthy lifestyle and to become informed about the right insurance policy they need in case of extraordinary events. Is this fair, or is “tough luck, try again next time” an inappropriate answer when it comes to health care? For example, if someone smokes for their entire life and needs treatment for lung cancer, is a society responsible for them? If the situation is a poor family who has a premature baby requiring months of intensive care, does your answer change?

9. State monopolized health care has practically become a part of Canada’s national identity. Many Canadian politicians call Canada’s health care system “the greatest in the world”. Do you agree with this statement?

10. With problems such as waiting times and rising costs facing the Canadian health care system, do think the idea that all Canadians should be guaranteed free and universal access to health care services is still feasible, or simply a utopian ideal?

11. Gopnik believes it would be politically impossible in Canada to return to an American-style health care system. Do you think the people of Canada would move towards an America-style health care system?

12. Do you believe Canadian health care is headed for crisis?

13. During the 2004 Canadian federal election, Paul Martin pledged to put more money into health care to reduce waiting times. Is this a viable solution? Do you believe Canadian health care can be improved while staying within the current system, or are reforms necessary?

14. If health care reforms are necessary, what systems should these reforms be modeled on?

15. Is the two-tier system a reasonable alternative to the current system in Canada?