A Single Payer System for the U.S.?

Dorothy Guellec

Americans are not correctly informed about the Canadian system. This may or may not be a conscious media effort, but I want to set the record straight. Healthcare delivery in Canada reflects the country's principles, in particular universal entitlement and equitable access. Despite efforts “to unhinge people from their firm hold on these principles, Canadians continue to strive towards a health care system that will all the fruits of the health sciences available to all our residents without hindrance of any kind”.

I prepared myself by reading “Universal Healthcare: what the U.S. can learn from the Canadian experience” by Pat and Hugh Armstrong with Claudia Fegan, M.D. In addition I had a long and very helpful chat with Colleen Fuller, a researcher and writer who focuses on health care issues in both the public policy arena and in the private marketplace. She was invited to make a presentation before the Senate Social Affairs Committee April 6,2000. I drew heavily from these two sources, and I am extremely grateful for all their material and interest.

The concept of Universal Healthcare for the whole country began in the province of Saskatchewan in 1947. Everyone in the province was covered for impatient care, regardless of financial resources or location. People in high places flocked to see the Saskatchewan plan in action. Other provinces were to follow as healthcare was a provincial responsibility, but the federal government had the financial resources. It is difficult to distill a 176 page book and numerous wonderful articles, but I will give an in depth outline as this forum permits, so that US readers can get the true story.

The road to what was later called the Canada Health Act was a rugged one. Physicians were against any notion of universal coverage, while union members were strongly in favor. No province could resist the federal offer of cash to help pay for hospital insurance, or the demands from citizens and research evidence. By 1961 all provinces had hospital insurance in place and “almost all Canadians were covered by a public plan”. Canadians could walk into a hospital, present their hospital card or health number, and be admitted. They neither saw a bill nor paid directly for basic services. The Canada Health Act, only 13 pages was introduced into Parliament in 1984 where it passed with unanimous consent. Basically the Act “stated that for every dollar citizens paid in user fees or extra billing the federal government would deduct a dollar from its cash transfer to the province concerned. Everyone must be covered for medically necessary hospital and doctor services – no extra fees could be attached to these services.” Under the earlier legislation only medical practitioners were covered. With the Canada Health Act the definition was changed and expanded.

Health, not merely illness was established as a public concern. Canadians believe in collective rights or entitlements or “universality” extended  “through and guaranteed in Canada's health and social and political environment.  Three of its five criteria – universal coverage, accessibility and comprehensiveness –have been supported through the funding relationships between federal and provincial governments, and between provinces and health care providers”.

What do Canadians get? They get hospitals, doctors, nursing home intermediate care service, adult residential service; home care service and ambulatory care service. Canada also has residential care facilities for the physically handicapped, the developmentally delayed, and the psychiatrically disabled. As the Armstrong's explain in their chapter “Getting Access” “More than 80% of the facilities for the developmentally delayed and the physically handicapped are nonprofit institutions that receive substantial government funding.” Coverage is comprehensive then, providing for basic needs, diagnosis and tests, treatment, supplies and equipment, drugs and other preparations, dentists, midwives, and includes the services of other practitioners.

The Act requires that doctors receive reasonable compensation. This is not socialized medicine. The federal government does not set fees; the doctors' associations with provincial governments negotiate them. Administrative costs are held down as doctors work without assistants to coordinate reimbursement, and thus spend dramatically less time and money on billing compared to the U.S. counterparts. Patients do not receive lengthy bills explaining every little item such as an aspirin. In fact patients do not receive bills at all. This intermediate layer is responsible for huge expenditures – the gatekeeper.

In the U.S. we could save about $36 billion a year if we had a “paperless hospital.” As Business Week reported, we could save by just using electronic communications for transmitting patient data. “The health sector makes up 13% of the GNP (this was in 1995) but only 1 to 2% of the budget is spent on information technology.” Banks spend 10%. Physicians and health professionals spend more than 50% of their time dealing with tasks that have no direct use for the patient. Can you imagine what would happen in the US if we eliminated all intermediate levels, doing away with these unnecessary costs? In addition, we would have to get rid of the profit motive, which puts stockholders first to satisfy the capitalistic bottom line.

We are slipping so far and so fast that we are not even aware of the insidious Bioethicists in our midst. Decision-making has been quietly co-opted by “bioethics”, a “genre of philosophical discourse practiced by an elite group of academics, philosophers, lawyers, and physicians, many of whom are openly hostile to the sanctity of life and the Hippocratic traditions that most people still take for granted.” But do not kid yourself this is all about money. It was bioethicists and moral philosophers who thought up “Futile Care Theory,” which allows doctors and health-insurance executives to deny, not merely high-tech interventions, but also such treatments as CPR and antibiotics to the profoundly disabled and people at the end of life. This last phrase could describe anyone who has a diagnosis from 6 months minimum to “a lifetime exceeding that of federal guidelines.” Even the Hastings Center, one of the world's most famous bioethics think tanks has jumped on the bandwagon. Daniel Callahan, co-founder of this research groups stated March 2,200 in The New England Journal of Medicine Sounding Board's article “Death and the Research Imperative” The federal government now defines a premature death as one that occurs before the age of 65 years. He did not say where this number comes from. Is it just a strange coincidence that Medicare starts at 65? He goes on, since “the concept of a premature death is only part biologic and is more obviously cultural, it might best be understood as a death that occurs before a person has lived long enough to experience the typical range of human possibilities and aspirations to work, to learn, to love, to procreate, and to see one's children grow up and become independent adults. On the whole, I believe a life span of 65 years is sufficient for these purposes, even if most of us would like to live longer.” Talk about rationing. This kind of thinking and reasoning is arbitrary, cruel, materialistic, elitist, and reminds us of the Third Reich policies. The notion that 65 is a human life span, and we should be grateful for every year after, is intensely personal and should not pass as public policy.

Alas, “there comes a time in any industry when the principles that have long governed its activity and operation no longer apply.” The health-care system the U.S. has reached this point. It is tottering not merely evolving toward some new form. Consumers no longer know who is ultimately responsible for their care, as managed care companies routinely drop groups over 65 or institute new rules. Doctors come and go and change affiliations.

Canada does not have a perfect system but its problems are not: (1) Financial (2) waiting lists (3) bureaucracy and power and privacy (4) choices and abuses (5) quality, technology, research and innovation. There are a few problems and that will be taken up in part II.

The Canadian health care system provides universal, accessible portable, comprehensive care at reasonable cost through a public insurance system. This system purchasers and providers, with the public insurance “scheme paying for services provided by others.” This provincially administered system allows for flexibility as well as choices for patients and providers. At the same time it permits planning to avoid unnecessary duplication and limitation on access. It enjoys more support from its citizens than can be claimed by the health care systems in other countries.