Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: TUESDAY, April 3, 1990 TAG: 9004030505
SECTION: EDITORIAL PAGE: A-11 EDITION: METRO
SOURCE: Bob Willis Associate Editor
DATELINE: LENGTH: Long
In truth, that method has a lot to recommend it. Canada has managed since 1971 to rein in health expenses and provide decent care for all its citizens. It has done so by switching to a unified system in which government pays for all care and controls the fees that doctors and hospitals may charge.
The Canadian method also offers fewer choices and alternatives for both provider and consumer. That is one reason it would meet a lot of resistance here.
American physicians say that Canadians do not get as good care, which in some instances means they do not have access to all the spectacular high-tech treatment that helps drive up the U.S. health-care bill. But then, not all Americans enjoy that access either: As many as 37 million of us lack health insurance, the financial key that opens the door to all that costly care.
Between the present U.S. system and the Canadian, then, the alternative would seem to be either (1) very good and potentially very expensive care for most citizens (with tens of millions left out), or (2) an adequate but somewhat lower level of care for everyone.
Even if - by some criteria - the Canadian system does perform at a lower level, it works. Two decades ago, Canada faced the same kind of spiraling costs as the United States did and still does. From 1950 to 1971, Canada's national health spending rose from 2.95 percent of gross national product to 7.4 percent. (In the same period, America's rose from 4.4 percent of GNP to 7.8 percent.)
In 1971, Canada instituted national health insurance. "For the next decade," says Editorial Research Reports, "medical inflation in Canada slowed and health care's share of GNP remained relatively constant. By 1981, medical spending accounted for only 7.7 percent of GNP in Canada while it was a record 9.2 percent in the United States." The latter figure still is rising, to more than 11 percent now.
Canadian medical care is free to everyone. Federal and provincial governments pay for it. Doctors are not government employees, as in Britain; they practice independently on a fee-for-service basis. The difference is that government decides each year what it will spend for health care, and doctors then are paid according to a fee schedule determined, in cooperation with doctors, by the provincial governments.
If doctors' total charges exceed the total amount in a province's medical allocation, the added funds must be taken from somewhere else in the provincial budget. This motivates the provincial government to pressure doctors to hold down expenses.
Also, Canadians cannot go outside the system to buy private supplemental health insurance; so this discourages physicians from charging more than the provincial schedule allows. Contrast that with the United States, where there are overlapping federal, state and local insurance programs, and where these compete with 1,500 private insurers.
What do Canadians get for all this? A bargain, it seems.
In 1986, Americans spent $1,926 per capita on health care. Canada spent the equivalent of 1,370 U.S. dollars per capita. Canadian life expectancy is almost two years more than Americans'. Their state of health appears to be far better: Canada's infant-mortality rate is 24 percent lower than the United States', while deaths from heart disease there are 20 percent lower than here. Even allowing for the fact that Canada's is a smaller and more homogeneous population, with fewer of our social problems that can impact on health, the differences are significant.
Such figures are nothing new. The United States spends far more on health care in actual dollars and as a percentage of its GNP than any other country in the world. Yet we lag behind most industrial nations in state of health. An awful lot of the $660 billion we're spending this year on health care is wasted - by some estimates, as much as 25 percent. Canada is getting much more for its money.
Canadian doctors do all right financially, too. Like their American counterparts, they have incomes in the top 1 percent of all professionals'. And while they may not pull in as many dollars as do American physicians, they have to spend much less of it on malpractice insurance.
The American Medical Association severely criticizes the Canadian system. The AMA says it leads to improper interference in decisions that should be left to the doctor and patient; provides less state-of-the-art technology; and makes patients wait much too long for hospital beds. Setting limits is something that has never seemed acceptable in U.S. health care.
But we are setting limits now. A. Eugene LeBlanc, executive director of policy development for the Ontario Ministry of Health, puts it this way:
"As a society, Canada chooses what it can afford to spend on health care. So do you. The fact that rare Americans have access to distinguished medical services, so that millions have none, seems like rationing to me. I have never understood why Americans stand for it."
That is hyperbole: Americans with access to distinguished medical services are not rare, and the millions without health insurance usually can get some charity care. But the differences LeBlanc alludes to are plain. Part of the reason Americans stand for it is that those who lack adequate care are a minority with little political clout.
But the unrestrained growth in U.S. health-care costs is steadily making adequate care more dear and less accessible to greater numbers of Americans. The Canadian model may not be an answer for the United States; in another column, I'll try to set out more of its purported drawbacks. But clearly, what we have now isn't working as it should.
by CNB