For Dr. Peter Cram, an American internist who spent most of his career practicing in Iowa City, Iowa, moving here about four years ago was almost a no-brainer.
He’s part of a small cohort of American doctors who, for personal or professional reasons, have moved north to practice in Canada’s single-payer system. Now when he sees patients, he doesn’t worry about whether they can afford treatment. He knows “everyone gets a basic level of care,” so he focuses less on their finances and more on actual medical needs.
Cram treats his move as a sort of life-size experiment. As a U.S.-trained physician and a health system researcher, he is now studying what he says is still a little-understood question: How do the United States and Canada — neighbors with vastly different health systems — compare in terms of actual results? Does one do a better job of keeping people healthy?
For all of the political talk, in many ways it is still an open question.
“The Canadian system is not perfect. Neither is the United States’,” Cram said over coffee in Toronto’s Kensington Market. “Anyone who gives you a sound bite and says this system should be adopted by this country … I think they’re being almost disingenuous.”
Still, American support for government-run, single-payer health care, once a fringe opinion, is picking up momentum.
Sen. Bernie Sanders, the Vermont independent who emphasized single-payer health care in his 2016 presidential bid, helped move Canada into the U.S. spotlight.
Lawmakers in California and New York have taken steps toward such programs on a statewide level, and the concept is a hot topic in gubernatorial campaigns in both Illinois and Maryland.
In addition, polling finds doctors and patients increasingly supportive, though the percentages in favor typically drop when questions are focused on the taxpayer costs of such a system.
In Canada, medical insurance comes through a publicly funded plan. And, while covering everyone, Canada still spends far less on health care than the United States does: just over 10 percent of its GDP, compared with the United States’ 18 percent.
To many American advocates, Canada’s health system sounds like the answer to the United States’ challenges.
But in Toronto, experts and doctors say the United States first must address a more fundamental difference. In Canada, health care is a right. Do American lawmakers agree?
“The U.S. needs to get on with the rest of the world and get an answer on that issue before it answers others,” said Dr. Robert Reid, a health quality researcher at the University of Toronto, who has practiced medicine in Seattle.
It’s an obvious disconnect, said Dr. Emily Queenan, a family doctor now practicing in rural Ontario. Queenan, 41, grew up in the United States and did her residency in Rochester, N.Y. By 2014, after about five years of frustrating battles with insurance companies over her patients’ coverage, she had enough. She found herself asking, why not Canada?
She moved north. Gone, she said, are the reams of insurance paperwork she faced in America. Her patients don’t worry about affording treatment.
“We have here a shared value that we all deserve access to health care,” said Queenan. “That’s something I never saw in the States.”
Sanders has pushed the discussion, with a “Medicare-for-All” bill in Congress and in a visit to Toronto this fall. It was part fact-finding mission and part publicity tour. On that trip, doctors, hospital leaders and patients painted a rosy picture where everyone gets top-notch care, with no worries about its cost to them.
“They have managed to provide health care to every man, woman and child without any out-of-pocket cost,” Sanders told reporters while speaking on the ground floor of Toronto General Hospital. “People come to a facility like this, which is one of the outstanding hospitals in Canada. They undergo a complicated heart surgery, and they leave without paying a nickel.”
It sounds idyllic. But the reality is more complicated.
While progressives tout the Canadian system for efficiently providing universal health care, the Commonwealth Fund, a nonprofit research group, puts it just two spots above the United States — which ranks last — in its health system assessment. It suggests that in timeliness, health outcomes and equitable access to care, Canada still has much to improve.
“If you deny there are trade-offs, I think you’re living in wonderland,” Cram said.
The Canadian Vibe
In Canada, everyone gets the same government-provided coverage. Provinces use federal guidelines to decide what’s covered, and there’s no cost sharing by patients.
“Come to our waiting room,” said Dr. Tara Kiran, a family doctor at St. Michael’s Hospital, in Toronto. “You will see people who are doctors or lawyers alongside people who are homeless or new immigrants. People with mental health issues or addiction issues together with people who don’t.”
But that insurance — which accounts for 70 percent of health spending in Canada —addresses only hospitals and doctors. Prescription medications, dentists, eye doctors and even some specialists aren’t covered. Most Canadians get additional private insurance to cover those.
In countries such as Britain or Germany people can opt out to buy private insurance. Canada prohibits private insurers from offering plans that compete with the government, a restriction some doctors are suing to lift. It’s not a popular view in Canada, experts said, but the implications are significant.
Here, the debate focuses more on bringing down health spending — a concern in the United States, too, but one often overtaken by politics.
Canada’s provinces put, on average, 38 percent of their budgets into health care, according to a 2016 report from the Canadian Institute for Health Information, a nonprofit organization. Canada’s single-payer system is supported by a combination of federal and provincial dollars, mostly raised through personal and corporate income taxes. (A few provinces charge premiums, which are income-based and collected with taxes.)
“We make improvements or change things only to have additional debates about other things. Those debates are constant, and they should be,” Reid said. “[But] most of what you hear in the U.S. is back to the tenor of the insurance framework, whether [they] should have Obamacare or not.”
Taxes in Canada are generally higher than in the United States. Canada, for instance, collects a levy on goods and services and also taxes wealthier citizens at a higher income tax rate.
But many here call that a concession worth making, and also note that they don’t have to pay separate premiums for health care as people in the United States do.
“We can’t have what we have if we don’t pay the taxes,” said Brigida Fortuna, a 50-year-old Toronto resident and professional dog groomer, while on her way to a medical appointment. “But you have to take care of your people. … If you don’t have good health care, you’re not going to have a good society.”
That said, it’s not a perfect system. Canadian health care doesn’t cover prescriptions, physical therapy and psychotherapy. And there’s the concern that Canadians wait longer for health care than would Americans with robust health coverage.
There are cases, Reid said, when cancer care in Canada is delayed enough to yield health problems. Ex-pat Cram pointed to research that suggests low-income people are likely to wait longer for medical care — which can result in worse health outcomes.
“We do have a two-tiered system,” he said. “Most know it. Few will admit it.”
Typically, experts said, people with serious medical needs will jump to the front of the line for medical care. Kathleen Wynne, Ontario’s Liberal Party premier, said the Canadian government is actively trying to improve wait times.
But so far, it’s unclear how effective that’s been. A 2017 report from the nonprofit Canadian Institute for Health Information found that wait times had dropped for hip fracture repairs. But waits for, say, MRIs and cataract surgery have actually gotten worse. Depending on their province, the average wait for cataract removal ranged from 37 days to 148 days.
Many patients, though, said the waits were a trade-off they were willing to make. Toronto-based Nate Kreisworth, a 37-year-old music composer and producer, called it an obvious choice.
“You are not going to die because you’re waiting,” he said on a recent sunny morning while walking with his dog near Kensington Market. “Better wait times for everything? Sure, why not. But as long as the major issues are being covered, then I don’t think it’s really much of an issue.”
As Fortuna put it: “If you go for a headache and someone else is going to lose their arm, of course they’re going to take care of that person. I’m OK with that, because someday that could be me, too.”
Waits aren’t the only concern, though. There’s financing — and what it would cost for the United States to implement a system like Canada’s.
Because Americans have higher expectations about what a health plan should cover, it would be more expensive to adapt a Canadian approach, said Dr. Irfan Dhalla, an internist and health quality researcher in Toronto. And the quality may differ from what they are used to.
And in Canada, “everyone gets Kmart care,” Cram said. “There’s no Neiman Marcus care.”
Of course, some amenities that drive up costs — fancier food, softer gowns or private rooms — don’t necessarily produce better results.
A 2017 study found that patients with cystic fibrosis fared better in Canada than in the United States. But on the other hand, 2015 research comparing surgical outcomes found better results in the United States than in Canada. The Commonwealth Fund’s most recent ranking places Canadian health outcomes above America’s, but only by two slots.
Even so, many Canadians said they couldn’t imagine living with an American system. It’s a question not just of efficiency, but of fairness. Kreisworth compared his experience to that of family members in the United States.
“I talk to my brother’s girlfriend who is a part-time worker who has no [health] benefits — who would just be sick and not go to the doctor because she couldn’t afford to pay,” he said. “I can’t imagine that here. It seems like — it’s so wrong. It just seems utterly wrong.”
–Shefali Luthra, Kaizer Health News
Chris A Pickett says
If Canada’s system is so great, WHY do so MANY Canadians come to the US for health care?………Hmmmm. There is already a single payer system in the US, it is called the VA healthcare system. And while for many the care at the VA is fine, the VA is also RIFE with problems. I think if you asked enough VETERAN’S, you will find many refuse to go to the VA do to poor service. If you want Canadian healthcare, immigrate to Canada.
A lot of Canadians come to the US for knee, shoulder and hip replacements. Why, because they have to wait months or years to get them in Canada. Taxes are much higher in countries with single payer system.
@ Chris A Pickett
You don’t know the difference between do, due, and dew? Educate yourself.
Dew is the condensation that collects on surfaces from the water vapor in the air. Dew is often associated with the morning, and the word dew is often used figuratively to mean freshness, youth, innocence. Dew is primarily used as a noun but may also be used as a verb, related words are dews, dewed, dewing. Dewy is the adjective form.
Do means to perform a task or action, to solve or work out a problem, to be adequate, to produce. Do is one of the top one thousand most frequently used words, according to the Oxford English Dictionary. Do is a verb, related words are does, did, done, doing.
Due means required or expected at a certain time. Due may also mean what someone deserves, dues may refer to expected fees. Due is also one of the top one thousand most frequently used words, according to the Oxford English Dictionary. Due may be used as an adjective, noun and adverb.
There is also to, too, and two.
Why do adults not know the difference? Poor education. Maybe only went up to the fifth grade I guess.
Grammarist, one of the many reasons we don’t make an issue of people’s grammar or spelling on this site, aside from the fact that we’d never have had Austen, Fitzgerald or Hemingway had their editors been that obtuse about it, is that there is zero connection between a person’s education—by which is meant an ability to think, to have insights, to contribute to the conversation—and that person’s grammatical or spelling skills. To make an issue of those is usually presumptuous, it’s showing off, it’s placing yourself above others on entirely spurious criteria created by the “educated” to reinforce their claim to something they only think, wrongly, others don’t have. Bad spelling, bad grammar, typos (our specialty here at FlaglerLive) are like false notes at a concert: if the music’s there, who cares? Ironically your comment contributed nothing to the topic suggested by the article. So please: leave the word policing to us. And as with all policing, we prefer a light, tolerant touch.
@Trump sniffers, fans of Fox and Fools, and other Republican diaper models
Here – wipe the unfounded lies from your mouths and take a break:
5 Myths About Canadian Health Care
“…So feel free to have a discussion about the relative merits of the U.S. and Canadian health care systems. Just stick to the facts…”
how many canadians receive health care in us
Make America Good Again
Absolutely NOT! I hope that Canada’s Healthcare System NEVER comes to America as that would be even WORSE than the Obamacare mess we have now. If you want to use their healthcare system move to Canada and see how YOU like. If you think your taxes are too high now, just bring Canada’s Healthcare System here. I have many Canadian friends and they pay an exorbitant amount of tax for their healthcare.
a tiny manatee says
A lot of americans go to costa rica for dental procedures and plastic surgery, hmm, I wonder why
All economic data suggest it helps the 99%. The 1% wont get rich off off death anymore. So the redneck propaganda machines that keep workers down wont allow it. Youll hear lies about wait time and other nonsense that simply isnt true the systems work in the first world. We are a second world country that exploits its poor is the only reason we dont have this system
Trumpsters invent, breed and multiply the lies their ignorance feeds and they try to transplant them on the rest of us.
I have a lady Canadian friend of mine that had very successful knee surgery at 82 years old in Toronto and long therapy and recovered fine. Her 98 years old husband strong man of all her life died of cancer at 99. I would say good longevity for having the “awful” described by some here, Medicare for all that is needed in our US. I agree also that health care should also be a right here, not only for the one’s that can afford to pay.
We need to waste less trillions defending the so called foreign democracies in distant lands and spend those trillions in our own and our jobs generating failing infrastructure repair, instead.
I eagerly await the day that y’all manage to make life fair for everyone.
It would be nice to know which Canadian city Dr. Cram chose. Without a dateline, we can only guess what “here” means. Apparently Toronto if the Kensington Market reference is a clue. Thanks for the article, though.
Of course we can have single-payer health care. All we have to do is get rid of our military like the Canadians did. Iran, North Korea, China & Russia think it would be a great idea.
I know here my family doctor spends 30 minutes in the computer filing forms and data versus 8 minutes with patients. I also receive tons of useless paperwork and Medicare books that make a large amount of money for printers and paper stock suppliers explaining the intrincate maze of our Medicare rules and rights trying to avoid fraud…but then you have these thieves let go free like the GOP FL Governor after they steal millions from Medicare anyway thru their owned HCA Columbia systems among others… What a scam that these rabid GOP’s and Trumpsters support when they cheer to do away with Medicare! Do away with the greedy thieves and jail them, not away with a system that was created to benefit all.
@ palmcoaster says:
December 29, 2017 at 9:20 am
I know here my family doctor spends 30 minutes in the computer filing forms and data versus 8 minutes with patients. I also receive tons of useless paperwork and Medicare books that make a large amount of money for printers and paper stock suppliers explaining the intrincate maze of our Medicare rules and rights trying to avoid fraud
BUT yet you want the same type of system for ALL other health care??? Some friend from Canada and she is going to have surgery on her knee in the USA over Canada. Why when in Canada it would be completely covered would they choose to have it done at a cost here? Well because it would be done in weeks from the office visit compared to months or even over a year waiting in Canada for a slot to open for such a simple procedure,
Choice = freedom. Let me decide how to care for myself! If I want Canada’s system and can’t get it in the U.S. then I’ll move to Canada, really. If I want obumer care then I will buy it. If I don’t, I won’t. America is the land of opportunity and choices. You are responsible for the result of your choices, not the government.
I have several friends and family members who live in Canada and absolutely LOVE their system! While ours is a “high profit” driven system, the Canadian system a more “patient care” motivated one. The FACTUAL analysis shows that the quality of care is higher in Canada, while theirs costs less. . . the same with England’s system.
There’s lots of data and analysis out there, for example:
@sherry, a decade old study based on questionable data.
???????thanmost. . . there are many, many comparisons that show Canada provides equal or better healthcarea for much less money. Take a good read:
Canadian vs. U.S. health care
Our health care system is neither rational nor moral, and it will almost certainly get worse under the present administration.
By Kenneth Krell, M.D.
Idaho Post-Register, May 17, 2017
Despite the U.S. spending twice as much per capita on healthcare compared to Canada, our northern neighbors have longer life expectancy (80.3 years vs. 78.6 years), lower infant mortality rates, lower rates of chronic cardiovascular disease and diabetes, and generally seem to get along quite well, thank you, despite spending 10 percent of GDP on healthcare as opposed to the U.S.’s 15 percent.
Some of that Canadian advantage has likely come from healthier living up north—obesity rates of 14 percent vs. the U.S.’s 30.6 percent, along with lower smoking rates and a generally healthier lifestyle.
It’s been unclear if their universal healthcare system — as opposed to our disjointed, hodgepodge of healthcare financing and delivery in the U.S. — is at least partially responsible for the differences in health outcomes.
A study in the April 18 “Annals of Internal Medicine” compares survival of patients with cystic fibrosis in the U.S. and Canada, with shocking results.
Median survival in both countries increased between 1990 and 2013; however, survival in Canada increased far more, with a median age of survival 10 years greater in Canada than the U.S. (50.9 years vs. 40.6 years).
Much of the difference could only be explained by the lack of healthcare coverage in U.S. patients. Canadians had a somewhat lower risk of death compared to U.S. patients with continuous or intermittent Medicare or Medicaid, but they had a whopping 77 percent lower risk compared with U.S. patients who had no health insurance. And—perhaps most damning—there was no advantage in survival for Canadians when compared with U.S. patients who had private insurance.
The differences in survival were attributable to the health insurance status of U.S. patients. If you had private insurance you survive at the same rate as Canadians — if you don’t, your life is at stake — with a median 10 year less survival.
As the authors state, “no statistically significant difference in risk of death was seen between Canadian patients and U.S. patients with other insurance (primarily private coverage)… The fact that the risk for death in the United States varied depending on the type of health insurance coverage raises the possibility that differences in the health care systems may explain part of the survival gap documented.”
An accompanying editorial states, “Now we are faced with the more difficult task of trying to identify and implement solutions to bridge this survival gap., which seem to be based on fundamental differences in the two nations’ health care systems.”
In Idaho, since the Affordable Care Act, the percentage of citizens without health coverage has fallen from 22 percent in 2011 to 14 percent in 2015. That’s still 237,372 people without health insurance, including 78,000 who fall through the Medicaid gap. Over 237,000 Idahoans at risk for the kind of adverse health outcomes this study demonstrates, all of whom, for health care, would be better off in any other civilized country.
What is clear is that, as Americans, our health care system is neither rational, ethical nor moral, and will almost certainly get worse under the present administration. As a result more people will die. And, as Americans, we must live with that obscene fact until we decide the deaths will stop by moving to a sensible, equitable universal healthcare delivery system that insures coverage—equally—for all Americans.
Dr. Krell is an intensivist at Eastern Idaho Regional Medical Center in Idaho Falls.
j. michael kelley says
Here is something for you to consider. Canada has a total population of just over 36 million. We have more people living in California than in all of Canada. America has just over 323 million people. The “Affordable Care Act” is in deep trouble because of Subsidizing the many by the few. In order to pay for a ‘Single Payer” system in this country, the amount of taxation it would require would be unacceptable to most I believe.
Here’s a great article with some factual analysis about the different types of systems available to us. . . if only the members of Congress acted in our behalf, instead of their personal wallets:
@j. michael kelley
“Here is something for you to consider. Canada has a total population of just over 36 million. We have more people living in California than in all of Canada. America has just over 323 million people…”
You describe a difference of scale, besides that, what is your point?
“…The “Affordable Care Act” is in deep trouble because of Subsidizing the many by the few…”
What is the trouble? Who are the many? We know the “many” aren’t members of the armed forces, or people whose health insurance is employment connected. The many doesn’t include medicare and/or other retirement health insured. So who are the many? And who are the few? Republicans have repealed the individual mandate. Congratulations on reducing the pool that pays for self insured individuals. Good luck with your new rates.
“…In order to pay for a ‘Single Payer” system in this country, the amount of taxation it would require would be unacceptable to most I believe.”
Stating the obvious to start, if we had a “single payer” it would largely replace other “payers” i.e., insurers. There would be no need for them or their marketing, overpaid executives, etc, etc. Maybe you’d miss the blizzard of bullshit in your mailbox, inbox, television, etc. I wouldn’t. The wealthy will always be served, they always were. What about the rest of us, a.k.a. the many?
Who pays for tricky ricky’s and desantis’ health insurance – “the few” – or the rest of us, a.k.a., the many?
WOW! A really great post, Pogo, and my thoughts exactly. . . after reading kelley’s comment.
It would be interesting to read some thought provoking factual research and analysis from the likes of the kelley’s of this world, but we both know that’s not going to happen because facts get in the way of prejudice.
Anyway, thanks for taking it to him!