The stunning implosion on Friday of the American Health Care Act, the Republican Party’s replacement for the Affordable Care Act (Obamacare), may have been a defeat for President Trump and his party, but it certainly isn’t the end of the push to reform health care in the United States.
The repeal and replace drama has understandably captivated the American media for weeks. But it isn’t just Americans who are fascinated by the unfolding story. International media outlets have also been covering each moment, as the world watches mostly with what seems to be incredulity. For people living in just about every country making up the Organization for Economic Co-operation and Development, in which universal health insurance is seen as both a mundane fact of life and practically a right of citizenship, the AHCA proposal is downright odd.
Nowhere is the incredulity more pronounced than among our neighbors to the north in Canada. As two physicians who have practiced medicine in Canada, now working respectively in Toronto and Boston, we ask this question: Are there lessons that Canada can teach America about health care, particularly in this time of change?
There seem to be two answers to this question: absolutely yes and absolutely no. Some describe the Canadian health care system as an example of health care at its best, the pinnacle of equity and excellence. Others portray it as a failed socialist experiment, a disaster so unmitigated that people die waiting for care.
Neither characterization is correct. The Canadian system for health care is complex, just as is the US system. There’s no question that Canadians have achieved undeniable success, accomplishing the double feat of providing universal health coverage for medically necessary services at low administrative cost. It is not without problems, including the often-overstated but real issue of long wait times for non-urgent care. But it has by and large contributed to better health outcomes than the US system at lower cost — Canada spends 11.2 percent of its gross domestic product on health care, the US spends 17.6 percent. This success makes the Canadian example worth considering for the US, or at least learning from.
How has Canada been effective at providing care and containing costs? We suggest two main reasons for its success, both of which offer lessons for the US.
First, to Canadians, health care is more than a matter of money and medicine: It is an expression of core national values. It’s no coincidence that the late Tommy Douglas, the former premier of Saskatchewan who introduced universal public health care to Canada, was chosen by Canadians from across the country to be “The Greatest Canadian of All Time” in 2004. Simply put, universal health care has become central to how Canadians think about their identity. It reflects a national determination to take care of each other at moments of vulnerability, and to place well-being over wealth.
To Canadians, health care is more than a matter of money and medicine: It is an expression of core national values.
This national aspiration has helped Canada weather discussion and debate for decades about the right way to reform the system because there is broad agreement on the fundamental goals and values that underpin it. In other words, when there is national agreement on the fundamental importance of health care for all, the remaining debate is around matters of fine-tuning and making the system better. Such agreement has eluded Americans for decades, leading to the enormous national debates around the ACA, and now the AHCA.
We suggest that a broader national conversation among Americans about our collective responsibility for health as a public good is essential if we are to find a solution that transcends this political moment.
Second, the feature that has likely been at the core of the Canadian health care system’s success is a federal requirement to provide insurance to cover all necessary doctor and hospital services, which has been part of the plan since its inception. Although actually providing health care is decentralized to 13 provinces and territories, each of these regions is required to provide free point-of-care treatment to all citizens through one central payer that guarantees coverage for an agreed-upon package of essential services.
The health care plan for each province and territory is shaped from that core guarantee of universal public coverage, bound together by national legislation. That has buffered Canadian health care from multiple challenges. This central, long-established, and legislated imperative also encourages the organization of the provision of medical services, the elevation of primary care to a central role in care coordination, and the rational allocation of resources to ensure that everyone has access to the care they need at all levels, from primary care to advanced and highly specialized “quaternary” care.
The US is challenged on both of these fronts. There is no national agreement on the core principles that inform American health care, and no attempt has been made to create a single legislative linchpin around which all other elaborations revolve. Since the ACA was first proposed, little of the debate was focused on the core building blocks needed to create a high-performing health care system. Rather than tackle the existential question of why Americans need universal health care in the first place, the conversation centered around patches that have been stitched together to create the flawed but critical coverage network that the ACA provides. This led to legislative compromises and deals struck between interest groups, all administered by a range of disparate stakeholders.
To make progress on providing sensible health care, the US needs to decide what having a health care “system” means to Americans. Is it simply a way to coordinate the exchange of dollars for care? Or is it an expression of our highest aspirations, an investment in the well-being of our communities?
If it is the latter, America would make an historic mistake by dismantling the ACA. Instead, its citizens and lawmakers should be clamoring to take the next step toward structuring our health care system in a way that will allow for organized delivery of care.
Single-payer systems, like the Canadian version, or a single provider system, as seen in the United Kingdom and other countries, provides the means of bringing care under the umbrella of a single, accountable authority. This is neither socialism nor an attack on individual liberty. It is simply making a promise: to protect each other from disease and preventable harm, recognizing that our capacity to do so is perhaps the most meaningful measure we have of our society’s worth.
It is heartening that recent national opinion polls suggest that Americans are beginning to agree with that promise. It is also becoming clearer that Americans care more about health care for all than previously thought. We could certainly look to our northern neighbors for a workable example of how this feeling can be translated into healthier populations, and a system that is geared towards well-being.
Danielle Martin, MD, is vice president for medical affairs and health system solutions at Women’s College Hospital in Toronto. Her latest book, “Better Now: Six Big Ideas to Improve Health Care for All Canadians,” was published in January. Sandro Galea is professor and dean of Boston University School of Public Health. His book, “Healthier: Fifty Thoughts on the Foundations of Population Health,” will be published in June.