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Oh, Canada, where health care for all 33 million is free

WINDSOR, Ontario

Ask Emily Whitehead, a Canadian, what she thinks about her country's health care system and she'll tell you a little story.

Years ago, she and a friend had babies at the same time. Afterward, they compared notes.

The friend, who lives in Michigan, was in the hospital for two or three days. Her bill: more than $3,000.

Whitehead, a diabetic, was in the hospital for two months. So was her premature infant, who at one point had to be transported in a specially equipped ambulance with two nurses and two paramedics.

Total bill for the Whiteheads: $16.95, for TV and a long-distance call.

Today, Whitehead is battling cancer, but once again the bill is the least of her worries. The Ontario government is paying for all of her hospital stays and doctor visits.

"When you consider the cost between the U.S. and Canada, there is no comparison,'' says her husband, Dennis. "People who go to the hospital here don't face financial ruin.''

Straddling the world's longest peaceful border, the two countries have much in common by virtue of language, culture and closely entwined economies. But there is a major difference — their approach to health care.

Canadians pay higher sales taxes — 13 percent in Ontario compared with 7 percent in Tampa — but all 33 million are entitled to hospital and physician services at government expense. No Canadian ever goes bankrupt because of medical bills.

Across the border, where Americans are declaring bankruptcy in near-record numbers, 62 percent of filings are at least partly because of health care costs. Some 46 million have no insurance. Millions more are underinsured.

And while the United States spends more per person on health care than any other country, Americans aren't even the world's healthiest. Canadians, Britons and residents of 27 other nations all live longer.

President Barack Obama wants Congress to pass a major health care reform bill before its August recess, saying, "We can't afford to wait."

The most contentious idea is a government-funded insurance option for those who might otherwise lack coverage. Critics howl, calling it socialized medicine that could drive private insurance companies out of business.

The controversy has focused attention, not all of it favorable, on Canada.

"Government-run health care systems like the one in Canada not only deny, but also delay care for weeks, months and even years,'' U.S. Sen. Mitch McConnell, a Kentucky Republican, recently charged.

Canadians freely admit that their system is not perfect, citing shortages of doctors in many places, often long waits for elective procedures like cataract surgery, too few nursing homes so the elderly often stay in hospitals far longer than they should, tying up beds.

But Canadians say that everyone who needs care gets it. And they say their single-payer system — doctors bill one payer, the government — is inherently more efficient than the U.S. system, in which payment might come from Medicare, Medicaid or countless private insurance plans, none of which cover exactly the same services or pay exactly the same amounts.

Dr. Diane Normandin learned that the hard way.

A graduate of Montreal's McGill University, Normandin moved to Clearwater in 1994 because she thought U.S. doctors had more freedom. But she spent an inordinate amount of time trying to tell whether a patient's insurance covered visits to a particular lab or specialist.

"You had maybe five minutes with the patient but 20 minutes of paperwork and the ridiculous sorting out of where the patient could go,'' says Normandin, who needed six employees to handle the workload. "It was crazy.''

In 2003 she went back to Canada and opened a family practice near Montreal. Now she has one employee.

• • •

The 1984 Canada Health Care Act (PDF) guarantees basic services for all citizens. But there are actually 10 separate health care systems run by the 10 provinces.

The largest is the Ontario Health Insurance Plan, or O-HIP, as everyone calls it. All Ontarians carry a green and white identification card, about the size of a driver's license, that they present at the doctor's office or hospital.

The patient never sees a bill. The doctor gets paid by the Ontario Ministry of Health according to fees negotiated between the ministry and the provincial medical association.

Fanning out a little sheaf of white slips, Dr. Jeffrey Turnbull says, "This is the total paperwork for 40 patients.''

President-elect of the Canadian Medical Association, Turnbull is chief of staff at the main hospital in Ottawa, Canada's capital. On a recent morning, he met with several residents, a nurse and a pharmacist to review the charts of patients admitted overnight.

Among them was Mrs. K, a chronic alcoholic. And Mr. R, with colon cancer. And Mrs. L, with a spinal injury.

Turnbull's team discussed each patient, ordering costly tests for several. Insurance was never mentioned.

"There was not one word today about could they afford anything,'' Turnbull says. "You would have heard that in the U.S.: 'We need to do a CAT scan. Oh, do they have insurance?' There were rich and poor on that list. The great asset we have in the health care system is its equitability.''

• • •

The No. 1 myth about the Canadian system is that egalitarian is the same as socialist.

In a true socialized system like Britain's, doctors work for the government. Most Canadian doctors work for themselves or in groups.

Nor has universal coverage driven private insurers out of business. Through their jobs or at their own expense, two-thirds of Canadians have insurance for dental work, eye care, prescription drugs and private hospital rooms — none of which are generally covered by the government plans.

A second pervasive myth: Canadians can't choose their own doctors.

The truth is they have a choice of doctors, though it is more limited than in the United States. Windsor, part of a metro area of 400,000, has five cardiologists; St. Petersburg (population 245,000) has more than 40.

A major reason for the shortage is that in the 1990s the government restricted medical school admissions, concerned that Canada would have too many doctors. "It underestimated population growth and aging,'' says Dr. Amr Morsi, a Windsor cardiologist.

The last myth? Canadian doctors are controlled by the government.

"I can do whatever test I want. I just happen to bill one payer, and that's the government,'' says Turnbull, the Ottawa physician.

He and others acknowledge that the government imposes de facto controls by not approving payment for tests considered experimental or of dubious value. Because Ontario is one of the few provinces that still doesn't pay for PET scans, used to diagnose cancer, doctors hesitate to order a scan that can cost a patient $2,400 out of pocket.

• • •

One irrefutable truth about the Canadian system is that people often have to wait weeks, even months, for non-emergency care.

Early last year, Don Praill of Amherstburg, Ontario, was told it would be nine months before he could have surgery for a painful back condition. His wife, Betty, went online and found a spinal institute in Tampa that could operate almost immediately.

But the cost, $40,000, was prohibitive. Praill finally had the surgery in Canada in January.

"A lot of people here have gone to Detroit because things are so much faster,'' Betty Praill says, "but in Canada everything is free.''

One reason for the long delays is a shortage of diagnostic equipment like MRIs and CAT scans. Canada has six MRI machines for every 1 million people; the United States has 26.

And "some surgeons are just known to be great and everyone migrates toward them so the wait times are longer,'' says Mark Fathers, controller of Windsor Regional Hospital. "It's not that the others are incompetent.''

In recent years, the provinces have made a major push to reduce waiting times, establishing benchmarks for treatment. In Ontario, at least 75 percent of cancer patients now start radiation within the prescribed four weeks. They get cataract surgery within four months and coronary bypass surgery, hip replacements and knee replacements within six months.

That is still far longer than Americans have to wait — assuming they have good insurance.

"Access to health care in the U.S. was fantastic. I was very impressed with the speed of care,'' says Raj Kumar Goel, a urologist who trained at the Cleveland Clinic before recently returning to Windsor. "But one of the challenges that was hard to swallow was seeing patients who had lost their jobs or had a change in insurance carriers not able to undergo surgery they had been booked for. In Canada that wouldn't happen.''

• • •

While critics of the U.S. health care system look to Canada for guidance, Canadians say they have learned a lot from Americans.

On visits to the States, David Musyj, president of Windsor Regional Hospital, picks up ideas that have transformed his once bland facility into a more welcoming place. There are umbrella bags for rainy days. Brahms' Lullaby is played for every newborn. On release, patients get Musyj's personal phone numbers to register complaints or praise.

"What has changed over the last 20 years is a clear focus on the patient and customer service,'' he says. "Previously, because the hospitals are free, the attitude was: 'If you don't like it, sit down and be quiet.' ''

Canadian hospitals are nonprofits that get most of their budget from the government but must raise the rest themselves. Windsor Regional and the city's other hospital, Hotel Dieu-Grace, have been able to spruce up rooms by charging local businesses $50,000 in exchange for naming rights. Patients might be in a room with "Devonshire Mall'' or "CKLW Radio'' over the door.

Canadians have also become more demanding because of reporting requirements that enable them to compare hospitals by infection rates, length of stay and other factors. Hospitals are almost obsessive about reducing emergency room waiting times that in major cities like Toronto have run as much as 36 hours.

"Every Monday morning we huddle and look at what we can to do knock off even five minutes,'' says Theresa Morris, director of Windsor Regional's ER, where average waits are within the target eight hours. But she notes that her hospital — like many others — is often at 100 percent capacity.

"When there's nowhere to put them upstairs,'' Morris says, "it gridlocks.''

• • •

The long waits have sparked a robust debate over whether Canada should move more closely to a U.S.-style system in which those who have money or good insurance can get faster access to health care.

In 2005, the Canadian Supreme Court struck down a Quebec law that banned private insurance for government-covered procedures, noting that some patients had died while waiting for public care. "Access to a waiting list is not access to health care,'' the court said.

Canada already has a number of private clinics that charge patients. The most controversial is one in Vancouver started by orthopedic surgeon Brian Day, former president of the Canadian Medical Association.

"In a free and democratic society . . . the state has no business preventing you and me from spending our own money on health care,'' Day told the New York Times in 2006, adding that a dog in Canada could get a hip replaced faster than a human could.

But critics say the growth of facilities like Day's would draw doctors, nurses and other resources away from Canada's public system, resulting in a two-tier system in which only the rich got top-notch care.

"My feeling is that we can fix the public system because I think that has the greatest potential,'' says Turnbull, the medical association's president-elect. He and others say waits could be reduced by greater use of electronic medical records, more emphasis on preventive care and more alternatives to hospitalization for the old and chronically ill.

"What's right about our system is that we have a single-payer system that's dramatically reduced costs and provided universal coverage,'' says Dr. Michael Rachlis, one of Canada's top experts on health care policy. "Americans have ideological blinders about 4,000 miles tall and cannot see that something with the word 'government' in it could be more efficient than something without government in it.''

Emily and Dennis Whitehead tend to agree. While she undergoes cancer treatment with no worries about the cost, an uninsured friend in Alabama is recovering from major heart surgery.

"I asked my friend how he's going to pay his $110,000 hospital bill and he has no idea,'' Dennis Whitehead says. "They'll probably turn it over to a collection agency and harass him for the rest of his life.''

Susan Taylor Martin can be contacted at

Country comparison

Canada United States
Population 33 million 307 million
Life expectancy, female 83.9 80.7
Life expectancy, male 78.7 75.6
Infant mortality per 1,000 5 6.3
Medical doctors per 1,000 2.1 2.4
MRI units per million 6.2 26.5
Health spending as % of GDP 10% 15.3%

Source: Organization for Economic Cooperation and Development

Oh, Canada, where health care for all 33 million is free 07/17/09 [Last modified: Sunday, July 26, 2009 11:23pm]
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