Posted on | February 28, 2017 | 7 Comments
In 2007, the Cambridge based National Bureau of Economic Research (NBER), self-defined as “the nation’s leading nonprofit economic research organization”, produced a singularly myopic white paper comparing the U.S. and Canadian health care systems. Noting that Canada is a “single-payer and mostly publicly-funded system” while the U.S. is a “multi-payer, heavily private system”, NBER stated that “Much of the appeal of the Canadian system is that it seems to do more for less.”
At the time of the paper, Canada was devoting about 10% of its GDP to health care versus 16% in the U.S. While spending less, Canada managed a significantly lower infant mortality rate, and higher life expectancy. The authors attempted to explain these negative findings by first noting that low birthweight is associated with high infant mortality, and then offering this analysis, “Low birthweight-a phenomenon known to be related to substance abuse and smoking-is more common in the U.S. For babies in the same birthweight range, infant mortality rates in the two countries are similar. In fact, if Canada had the same proportion of low birthweight babies as the U.S., the authors project that it would have a slightly higher infant mortality rate.”
Moving next to the troublesome issue of life expectancy, they declared, “The gap in life expectancy among young adults is mostly explained by the higher rate of mortality in the U.S. from accidents and homicides. At older ages much of the gap is due to a higher rate of heart disease-related mortality in the U.S. While this could be related to better treatment of heart disease in Canada, factors such as the U.S.’s higher obesity rate (33 percent of U.S. women are obese, vs. 19 percent in Canada) surely play a role.”
That the NBER economists could present such arguments with a straight face well illustrates the remarkable disconnect between cause and effect, prevention and intervention, and scientific progress versus human progress in the U.S. health care system and its Medical-Industrial Complex. Eight years later Canada would boast a life expectancy of 82.2 years and an infant mortality rate of 4.9/1000 live births versus U.S. numbers of 79.3 years and 6.5/1000 live births. It should be noted as well that the per capita health care expenditure in Canada at the time was $5,292 compared to $9,403 in the U.S.
At the same time as the privately and opaquely funded NBER economists were penning their insights, actual public health leaders in Canada, after two years of thought and debate in the public square on a vision that would govern Canadian health care into the future, released its’ “ten year plan”. It included these five principles:
1)”Prevention is a priority. Canadians value their health.
2) They prefer to live a long life in good health while preventing disease or injury, rather than experiencing severe illness and the pain, suffering and loss of income that they can cause; they also want to avoid premature death.
3) Promoting good health just makes sense. While we have the means to prevent or delay many health problems, Canada’s current health system is mainly focused on diagnosis, treatment and care.
4) To create healthier populations, and to sustain our publicly funded health system, a better balance between prevention and treatment must be achieved.
5)Prevention is a hallmark of a quality health system. Internationally, health promotion and prevention are recognized as essential pieces of high-quality health systems.”
In a remarkably insightful summary, Canada’s national, provincial and territorial public health leaders declared:
“Health promotion is everyone’s business. While it is clear that health services are a determinant of health, they are just one among many. Others include:
1)environmental, social and economic conditions;
2)access to education;
3)the quality of the places where people live, learn, work and play;
4)and community resilience and capacity.
Because many of these determinants of health lie outside the reach of the health sector, many of the actions to improve health also lie outside the health sector, both within and beyond government. This means that many government departments and a wide range of people and organizations in communities and across society play a role in creating the conditions for good health that support individuals in adopting healthy lifestyles. Promoting health and preventing diseases is everyone’s business—individual Canadians, all levels of government, communities, researchers, the non-profit sector and the private sector each have a role to play.”
This is not to say that the Canadian health care system is perfect. Far from it. The Commonwealth Fund in 2016 compared performance of 11 developed nations on measures of quality, cost, access and communication. The charts below are derived from that survey and compare Canada, the U.S., and the average of all 11 nations.
On Quality: The U.S. compares favorably on having a regular doctor, receiving good care, and having patients drug lists reviewed. We are also a bit ahead of Canada in team care since they rely more heavily on private fee-for -service doctors. But when patients assess whether our system as a whole is optimal and whether it works well and needs only minor changes, it is clear our citizens lack confidence compared to the Canadians, and that the Canadians trail the national average.
On Cost: The Canadian system does not cover dentists, eyeglasses or pharmaceuticals. If citizens want coverage for these they must purchase a private plan. Even so, the chart above clearly illustrates that U.S. citizens by significant margins feel greater financial stress than their neighbors to the north and purposefully ration their own care by avoiding necessary but expensive treatment.
On Access: On nearly every measure, Canadians score worse on access to care than do the Americans. These are issues they have focused on for over a decade and not resolved. The waits are concentrated in the area of elective surgery and specialty referral. They have the same number of doctors per 100,000 as do Americans but have not added physician extenders and team approaches to the degree the U.S. has. Instead, they have fallen back on ED visits in the off hours, which are free, resulting in long waits after hours.
On Communications: The results are mixed. Canadians lag in their use of online medical records though the U.S. has a long way to go as well. The American system shows the signs of excessive complexity with more repeat and unnecessary tests, more breakdowns in communication between generalists and specialists, and information unavailable at the time of appointment.
By moving toward universal care, adjusting our payment incentives, inserting performance bonuses to coax quality measures and electronic medical records, President Obama was heading in the right direction. But the Republicans seem determined to roll back the clock, insert even greater complexity, and place a greater burden on vulnerable populations who’s greatest need is simplicity and clarity.
What will happen next? We’ll look at that next week.