T

he 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?

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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.

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  • Dr. Tedone. You wrote “Yes, you benefited economically but so would one who was insured in the US.”
    You did not mention all of those who are uninsured, those who will lose their Medicaid coverage if Trump’s health care plan is ever successful, and all those co-payments and extra fees. If you are very wealthy in the US, no problem obtaining quality healthcare. A large percentage of your population are not wealthy and will not benefit under your existing system.

    • The problem with the ACA is that it extended Medicaid to include a higher income threshold. It also mandated what has to be covered. So it included another 10 M people but the new mandated coverage raised premiums for the 170 M who were covered and now their insurance is not afforable and deductibles are too high. Medicaid is insurance but not Health care. THe Government contracts out the coverage to plans whose reimbursement rate is so low that it costs money to see the patient. Many docs refuse to see Medicaid patients.
      What should be done is everyone should be able to buy insurance across state lines. People should buy the coverage and deductible they want. The government should subsidize the premiums for those who cannot afford them. Market forces will drive HC costs down as people shop.
      The government should negotiate drug prices with pharmaceutical companies. the ACA gave this up and that is the reason why drugs are so expensive. Also the government should facilitate use of generics.
      The mandated coverage of the ACA has made insurance too expensive for everyone.
      We may have to treat Health insurance and pharmaceutical companies as utilities. We do this for electricity and HC is more important.

  • Dr. Tedone, I’ve got a comparison between Canada and the US based on my two sons’ upper extremity injuries. One son had an injury in Canada & one son had an injury in the US. The US child’s story was covered by HealthWatchUSA’s webcast audio “YouTube Emily Paterson-Preventable Adverse Events,” and I will be a patient advocate speaker at their November HealthWatchUSA conference. I was also in the NEJM Medical Error discussion and other projects. In our case, we really can say that we prefer the Canadian system, and it was much cheaper.

  • My Ontario aunt and I have the same foot problem. She had wonderful treatment–totally free. I got the same US treatment, and my BCBS insurance denied partial coverage–nightmarish. In addition, my child had a preventable adverse event in the US healthcare system. A Canadian doctor helped me understand aspects of the harm which I hadn’t appreciated. I’m envious of my Canadian relatives’ healthcare, and they are scared of visiting the US and needing healthcare. Of course, we’ve got good providers in both countries.

  • Wow! For an article that sounded like it would look at both the pluses and minuses, it appears that the only minus is long waits for non urgent care. Yet two of the three comments so far seem to be negative toward the Canadian system.

    I have been involved in US health care finance and Administration for over 40 years. The issue of US health care as a national right vs a commodity had been debated for that entire time as have been comparisons to the Canadian system. So why don’t we have government run health care for all in the US? Basically, we do not see the government as the answer for working Americans. We do provide a system for the elderly – Medicare – and younger, less fortunate people – Medicaid and Children’s Health Insurance. Working age people get insurance through their employers. We do have access to care and have superb providers with great technology.

    Our issues are affordability and a focus on tertiary care over primary care. That is why we spend so much.

    American experts have looked at health status data and international models for years and have largely rejected them. Why? Because the bedrock principle of individual liberty will not be forsaken in the name of health status as administered by the government.

    That’s just the way it is. So please stop lamenting that.

    • So let me get this right, Jim. You would rather pay more, and get a worse outcome for your healthcare, than tolerate state regulation and intervention (not necessarily a complete take over) of the healthcare system?

      You know, I really, really have no idea why you would say that. Would you also rather every road in the US be privatized, and have a market for tolls (or however you’d structure it), just to have ‘choice’ and ‘individual liberty’ to pay more for a worse system?

      Markets do work for many (perhaps most) things, and individual freedom is also important. But we can also have the individual freedom to choose to pay into a common pot that then serves a collective purpose, you know, in those cases that markets fail.

      Every other developed country in the world (pretty much) has universal healthcare that is heavily regulated, and they have better outcomes, coverage for everyone, and spend substantially less on healthcare. But you are saying you simply don’t want that.

  • As a recently-retired Canadian oncologist, I can confirm that the Canadian single-payer system, although far from perfect, fulfils its mandate overall. While it is true that wait times for non-essential services often may be long, and need to be improved, for those with cancer or heart disease, or in need of acute tertiary care for medical or surgical emergencies, the system jumps to the pump with outcomes as good as anywhere in the world, often better.

  • Canada & UK are small countries with monolithic citizens. US is much different. A market based system would work best for us.

    • Are you really claiming that Canada and UK are made up of one type of people? That’s grossly inaccurate.

    • Dr. Vincent, from your comments it appears you have probably never visited Canada or the UK with an open mind. “Monolithic” is a word for one is ill informed about the world outside of the US. Your market based system is clearly struggling and expensive. It will ultimately fail. Life spans in Canada are better than the US and infant mortality is lower. Waiting times for elective procedures in Canada, such as joint replacements, may be longer, but everyone can get the care they need without going into bankruptcy. As a family physician for over 40 years, I can confirm any urgent problem can be dealt with rapidly and appropriately. Often it just takes a telephone call.

  • As a Canadian GP, to say there are long wait times for non-urgent care is misleading, there are long wait times for urgent care as well.

    • My response to John is that I was a practicing physician for 30 years and had many patients come to my practice to have timely state of the art surgery. I also have first-hand experience of the system in Germany and England. In both systems, there is a thriving private sector b/c of inadequacies of the state-run system. To Mariah I respond that the Candian population although diverse and under 30 M does not compare with the diversity and numbers of that diversity in a population of 320 M

    • Since reading this article, my oldest son had an accident in Canada, 6/2017. His hospital care was provided by a well-trained, pleasant, plentiful, staff in a clean, busy facility. We got free, complete medical records to take with us, and we were allowed to photograph the procedure which cost about 1/3 of what a US facility would have charged. We were surprised that there was no additional cost for things like anesthesia—simply included in general ER costs, so no incentive for padding a bill. Back in the US, our son is on a conveyor belt system for follow-up care which includes seeing a specialist who has 7 physician assistants working under him. The US seems so chaotic, expensive and fragmented by comparison. Thank you Canada!

    • Emily your son, unfortunately, was involved in an accident which required emergency care. There is no bureaucracy involved in that situation his care was an emergency. Yes, you benefited economically but so would one who was insured in the US.

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