I was once a believer in socialized medicine. As a Canadian, I had soaked up the belief that government-run health care was truly compassionate. What I knew about American health care was unappealing: high expenses and lots of uninsured people.
My health care prejudices crumbled on the way to a medical school class. On a subzero Winnipeg morning in 1997, I cut across the hospital emergency room to shave a few minutes off my frigid commute.
Swinging open the door, I stepped into a nightmare: the ER overflowed with elderly people on stretchers, waiting for admission. Some, it turned out, had waited five days. The air stank with sweat and urine. Right then, I began to reconsider everything that I thought I knew about Canadian health care.
I soon discovered that the problems went well beyond overcrowded ERs. Patients had to wait for practically any diagnostic test or procedure, such as the man with persistent pain from a hernia operation whom we referred to a pain clinicwith a three-year wait list; or the woman with breast cancer who needed to wait four months for radiation therapy, when the standard of care was four weeks.
Government researchers now note that more than 1.5 million Ontarians (or 12% of that province's population) can't find family physicians. Health officials in one Nova Scotia community actually resorted to a lottery to determine who'd get a doctor's appointment.
These problems are not unique to Canadathey characterize all government-run health care systems.
Consider the recent British controversy over a cancer patient who tried to get an appointment with a specialist, only to have it canceled48 times. More than 1 million Britons must wait for some type of care, with 200,000 in line for longer than six months. In France, the supply of doctors is so limited that during an August 2003 heat wavewhen many doctors were on vacation and hospitals were stretched beyond capacity15,000 elderly citizens died. Across Europe, state-of-the-art drugs aren't available. And so on.
Single-payer systemsconfronting dirty hospitals, long waiting lists and substandard treatmentare starting to crack, however. Canadian newspapers are filled with stories of people frustrated by long delays for care. Many Canadians, determined to get the care they need, have begun looking not to lotteriesbut to markets.
Dr. Jacques Chaoulli is at the center of this changing health care scene. In the 1990s, he organized a private Quebec practicepatients called him, he made house calls and then he directly billed his patients. The local health board cried foul and began fining him. The legal status of private practice in Canada remained murky, but billing patients, rather than the government, was certainly illegal, and so was private insurance.
Eventually, Chaoulli took on the government in a case that went all the way to the Supreme Court. Representing an elderly Montrealer who had waited almost a year for a hip replacement, Chaoulli maintained that the patient should have the right to pay for private health insurance and get treatment sooner. A majority of the court agreed that Quebec's charter did implicitly recognize such a right.
The monumental ruling, which shocked the government, opened the way to more private medicine in Quebec. Though the prohibition against private insurance holds in the rest of Canada for now, at least two people outside Quebec, armed with Chaoulli's case as precedent, are taking their demand for private insurance to court.
Consider, too, Rick Baker. He isn't a neurosurgeon or even a doctor. He's a medical brokerone member of a private sector that is rushing in to address the inadequacies of Canada's government care. Canadians pay him to set up surgical procedures, diagnostic tests and specialist consultations, privately and quickly.
Baker describes a man who had a seizure and received a diagnosis of epilepsy. Dissatisfied with the opinionhe had no family history of epilepsy, but he did have constant headaches and nausea, which aren't usually seen in the disorderhe requested an MRI.
The government told him that the wait would be 4 1/2 months. So he went to Baker, who arranged to have the MRI done within 24 hoursand who, after the test revealed a brain tumor, arranged surgery within a few weeks. Some services that Baker brokers almost certainly contravene Canadian law, but governments are loath to stop him.
Other private-sector health options are blossoming across Canada, and the government is increasingly turning a blind eye to them, too, despite their often uncertain legal status. Private clinics are opening at a rate of about one a week.
Canadian doctors, long silent on the health care system's problems, are starting to speak up. Last August, they voted Brian Day president of their national association. Day has become perhaps the most vocal critic of Canadian public health care, having opened his own private surgery center and challenging the government to shut him down.
And now even Canadian governments are looking to the private sector to shrink the waiting lists. In British Columbia, private clinics perform roughly 80% of government-funded diagnostic testing.
This privatizing trend is reaching Europe, too. Britain's Labour Partywhich originally created the National Health Servicenow openly favors privatization. Sweden's government, after the completion of the latest round of privatizations, will be contracting out some 80% of Stockholm's primary care and 40% of its total health services.
Since the fall of communism, Slovakia has looked to liberalize its state-run system, introducing co-payments and privatizations. And modest market reforms have begun in Germany.
Yet even as Stockholm and Saskatoon are percolating with the ideas of Adam Smith, a growing number of prominent Americans are arguing that socialized health care still provides better results for less money.
Politicians like Hillary Clinton are on board; Michael Moore's new documentary, "Sicko," celebrates the virtues of Canada's socialized health care; the National Coalition on Health Care, which includes big businesses like AT&T, recently endorsed a scheme to centralize major health decisions to a government committee; and big unions are questioning the tenets of employer-sponsored health insurance.
One often-heard argument, voiced by the New York Times' Paul Krugman and others, is that America lags behind other countries in crude health outcomes. But such outcomes reflect a mosaic of factors, such as diet, lifestyle, drug use and cultural values. It pains me as a doctor to say this, but health care is just one factor in health.
Americans live 75.3 years on average, fewer than Canadians (77.3) or the French (76.6) or the citizens of any Western European nation save Portugal. Health care influences life expectancy, of course. But a life can end because of a murder, a fall or a car accident. Such factors aren't academichomicide rates in the U.S. are much higher than in other countries.
In The Business of Health, Robert Ohsfeldt and John Schneider factor out intentional and unintentional injuries from life-expectancy statistics and find that Americans who don't die in car crashes or homicides outlive people in any other Western country.
And if we measure a health care system by how well it serves its sick citizens, American medicine excels. Five-year cancer survival rates bear this out. For leukemia, the American survival rate is almost 50%; the European rate is just 35%. Esophageal carcinoma: 12% in the U.S., 6% in Europe. The survival rate for prostate cancer is 81.2% here, yet 61.7% in France and down to 44.3% in Englanda striking variation.
Like many critics of American health care, though, Krugman argues that the costs are just too high: health care spending in Canada and Britain, he notes, is a small fraction of what Americans pay. Again, the picture isn't quite as clear as he suggests. Because the U.S. is so much wealthier than other countries, it isn't unreasonable for it to spend more on health care. Take America's high spending on research and development. M.D. Anderson in Texas, a prominent cancer center, spends more on research than Canada does.
That said, American health care is expensive. And Americans aren't always getting a good deal. In the coming years, with health expenses spiraling up, it will be easy for some to give in to the temptation of socialized medicine. In Washington, there are plenty of old pieces of legislation that like-minded politicians could take off the shelf, dust off and promote: expanding Medicare to Americans 55 and older, say, or covering all children in Medicaid.
But such initiatives would push the U.S. further down the path to a government-run system and make things much, much worse. True, government bureaucrats would be able to cut costsbut only by shrinking access to health care, as in Canada, and engendering a Canadian-style nightmare of overflowing emergency rooms and yearlong waits for treatment.
America is right to seek a model for delivering good health care at good prices, but we should be looking not to Canada, but close to homein the other four-fifths or so of our economy. From telecommunications to retail, deregulation and market competition have driven prices down and quality and productivity up. Health care is long overdue for the same prescription.
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