Canadian and American health care systems compared
Encyclopedia
Comparison of the health care systems in Canada and the United States are often made by government, public health
and public policy analysts. The two countries had similar health care system
s before Canada
reformed its system in the 1960s and 1970s. The United States
spends much more money on health care than Canada, on both a per-capita basis and as a percentage of GDP. In 2006, per-capita spending for health care in Canada was US$3,678; in the U.S., US$6,714. The U.S. spent 15.3% of GDP on health care in that year; Canada spent 10.0%. In 2006, 70% of health care spending in Canada was financed by government, versus 46% in the United States. Total government spending per capita in the U.S. on health care was 23% higher than Canadian government spending, and U.S. government expenditure on health care was just under 83% of total Canadian spending (public and private) though these statistics don't take into account population differences.
Studies have come to different conclusions about the result of this disparity in spending. A 2007 review of all studies comparing health outcomes in Canada and the US in a Canadian peer-reviewed medical journal found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Life expectancy is longer in Canada, and its infant mortality rate is lower than that of the U.S., but there is debate about the underlying causes of these differences. One commonly-cited comparison, the 2000 World Health Organization
's ratings of "overall health service performance", which used a "composite measure of achievement in the level of health, the distribution of health, the level of responsiveness and fairness of financial contribution", ranked Canada 30th and the U.S. 37th among 191 member nations. This study rated the US "responsiveness", or quality of service for individuals receiving treatment, as 1st, compared with 7th for Canada. However, the average life expectancy for Canadians was 80.34 years compared with 78.6 years for residents of the U.S.
A 2004 study found that Canada had a slightly higher mortality rate for acute myocardial infarction (Heart Attack) because of the more conservative Canadian approach to revascularizing (opening) coronary arteries.
The WHO's study methods were criticized by some analyses.
Although there is a measure of consensus that life-expectancy and infant mortality mark the most reliable ways to compare nation-wide health care, a recent report by the Congressional Research Service
carefully summarizes some recent data and notes the "difficult research issues" facing international comparisons.
The health care system in Canada
is funded by a mix of public (70%) and private (30%) funding, with most end-services delivered by private providers.
Through all entities in its public-private system
, the U.S. spends more per capita than any other nation in the world, but is the only wealthy industrialized country in the world that lacks some form of universal health care
. In March 2010, the US Congress passed regulatory reform of the American health insurance
system. However since this legislation is not fundamental health care
reform, it is unclear what its effect will be and as the new legislation is implemented in stages, with the last provision in effect in 2018, it will be some years before any empirical evaluation of the full effects on the comparison could be determined.
Health care costs in both countries are rising faster than inflation. As both countries consider changes to their systems, there is debate over whether resources should be added to the public or private sector. Although Canadians and Americans have each looked to the other for ways to improve their respective health care systems, there exists a substantial amount of conflicting information regarding the relative merits of the two systems. In Canada, the United States is used as a model and/or as a warning against increasing private sector involvement in financing health care. In the U.S., meanwhile, Canada's mostly monopsonistic
health system is seen by different sides of the ideological spectrum as either a model to be followed or avoided.
It is important to note that the Canadian healthcare system is actually composed of at least 10 mostly autonomous provincial healthcare systems, and a federal system which covers veterans. This causes a significant degree of variation in funding and coverage within the country.
Canada and the United States had similar health care systems in the early 1960s, but now have a different mix of funding mechanisms. Canada's universal single-payer health care
system covers about 70% of expenditures, and the Canada Health Act
requires that all insured persons be fully insured, without co-payments or user fees, for all medically necessary hospital and physician care. About 91% of hospital expenditures and 99% of total physician services are financed by the public sector. Ophthalmology and dental services account for a lot of the private expenditures in Canada. In the United States, with its mixed public-private system, 16% or 45 million American residents are uninsured at any one time. The U.S. is one of two OECD countries not to have some form of universal health coverage, the other being Turkey. Mexico established a universal healthcare program by November 2008.
The governments of both nations are closely involved in health care. The central structural difference between the two is in health insurance
. In Canada, the federal government is committed to providing funding support to its provincial governments for health care expenditures as long as the province in question abides by accessibility guarantees as set out in the Canada Health Act
, which explicitly prohibits billing end users for procedures that are covered by Medicare
. While some label Canada's system as "socialized medicine," the term is inaccurate. Unlike systems with public delivery, such as the UK, the Canadian system provides public coverage for private delivery. As Princeton University health economist Uwe E. Reinhardt notes, single-payer systems are not "socialized medicine" but "social insurance" systems, because doctors are in the private sector. Similarly, Canadian hospitals are controlled by private boards and/or regional health authorities, rather than being part of government.
In the U.S., direct government funding of health care is limited to Medicare
, Medicaid
, and the State Children's Health Insurance Program
(SCHIP), which cover eligible senior citizens, the very poor, disabled persons, and children. The federal government also runs the Veterans Administration
, which provides care to veterans, their families, and survivors through medical centers and clinics.
The U.S. government also runs the Military Health System. In Fiscal Year 2007, the MHS had total budget authority of $39.4 billion and served approximately 9.1 million beneficiaries, including Active Duty personnel and their families and retirees and their families. The MHS includes 133,000 personnel, 86,000 military and 47,000 civilian, working at more than 1,000 locations worldwide, including 70 inpatient facilities and 1,085 medical, dental, and veterinary clinics.
One study estimates that about 25 percent of the uninsured in the U.S. are eligible for these programs but remain unenrolled; however, extending coverage to all who are eligible remains a fiscal and political challenge.
For everyone else, health insurance must be paid for privately. Some 59% of U.S. residents have access to health care insurance through employers, although this figure is decreasing, and coverages as well as workers' expected contributions vary widely. Those whose employers do not offer health insurance, as well as those who are self-employed or unemployed, must purchase it on their own. Nearly 27 million of the 45 million uninsured U.S. residents worked at least part-time in 2007, and more than a third were in households that earned $50,000 or more per year.
Despite the greater role of private business in the U.S., federal and state agencies are increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on medical care in 2004. The U.S. government spends more on health care than on Social Security and national defense combined, according to the Brookings Institution
.
Beyond its direct spending, the U.S. government is also highly involved in health care through regulation and legislation. For example, the Health Maintenance Organization Act of 1973
provided grants and loans to subsidize Health Maintenance Organizations and contained provisions to stimulate their popularity. HMOs had been declining before the law; by 2002 there were 500 such plans enrolling 76 million people.
The Canadian system has been 69–75% publicly funded, though most services are delivered by private providers, including physicians (although they may derive their revenue primarily from government billings). Although some doctors work on a purely fee-for-service basis (usually family physicians), some family physicians and most specialists are paid through a combination of fee-for-service and fixed contracts with hospitals or health service management organizations.
Canada's universal health plan does not cover certain services. Non-cosmetic dental care
is covered for children up to age 14 in some provinces. Outpatient prescription drugs are not required to be covered, but some provinces have drug cost programs that cover most drug costs for certain populations. In every province, seniors receiving the Guaranteed Income Supplement have significant additional coverage; some provinces expand forms of drug coverage to all seniors, low-income families, those on social assistance, or those with certain medical conditions. Some provinces cover all drug prescriptions over a certain portion of a family's income. Drug prices are also regulated, so brand-name prescription drugs are often significantly cheaper than in the U.S. Optometry
is only covered in some provinces and is sometimes only covered for children under a certain age. Visits to non-physician specialists may require an additional fee. Also, some procedures are only covered under certain circumstances. For example, circumcision
is not covered, and a fee is usually charged when a parent requests the procedure; however, if an infection or medical necessity
arises, the procedure would be covered.
According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly.
In the U.S., the federal government does not guarantee universal health care
to all its citizens, but publicly funded health care programs help to provide for the elderly, disabled, the poor, and children. The Emergency Medical Treatment and Active Labor Act
or EMTALA also ensures public access to emergency services. The EMTALA law forces emergency health care providers to stabilize an emergency health crisis and cannot withhold treatment for lack of evidence of insurance coverage or other evidence of the ability to pay. EMTALA does not absolve the person receiving emergency care of the obligation to meet the cost of emergency health care not paid for at the time and it is still within the right of the hospital to pursue any debtor for the cost of emergency health care provided. In Canada, emergency room treatment for legal Canadian residents is not charged to the patient at time of service but is met by the government.
According to the United States Census Bureau
, 59.3% of U.S. citizens have health insurance
related to employment, 27.8% have government-provided health-insurance; nearly 9% purchase health insurance directly (there is some overlap in these figures), and 15.3% (45.7 million) were uninsured in 2007. An estimated 25 percent of the uninsured are eligible for government programs but unenrolled. About a third of the uninsured are in households earning more than $50,000 annually. A 2003 report by the Congressional Budget Office found that many people lack health insurance only temporarily, such as after leaving one employer and before a new job. The number of chronically uninsured (uninsured all year) was estimated at between 21 and 31 million in 1998. Another study, by the Kaiser Commission on Medicaid and the Uninsured, estimated that 59 percent of uninsured adults have been uninsured for at least two years. One indicator of the consequences of Americans' inconsistent health care coverage is a study in Health Affairs that concluded that half of personal bankruptcies involved medical bills. Although other sources dispute this, it is possible that medical debt
is the principal cause of bankruptcy in the United States
.
A number of clinics
provide free or low-cost non-emergency care to poor, uninsured patients. The National Association of Free Clinics claims that its member clinics provide $3 billion in services to some 3.5 million patients annually.
A peer-reviewed comparison study of health care access in the two countries published in 2006 concluded that U.S. residents are one third less likely to have a regular medical doctor, one fourth more likely to have unmet health care needs, and are more than twice as likely to forgo needed medicines. The study noted that access problems "were particularly dire for the US uninsured." Those who lack insurance in the U.S. were much less satisfied, less likely to have seen a doctor, and more likely to have been unable to receive desired care than both Canadians and insured Americans.
Another cross-country study compared access to care based on immigrant status in Canada and the U.S. Findings showed that in both countries, immigrants had worse access to care than non-immigrants. Specifically, immigrants living in Canada were less likely to have timely Pap tests compared with native-born Canadians; in addition, immigrants in the U.S. were less likely to have a regular medical doctor and an annual consultation with a health care provider compared with native-born Americans. In general, immigrants in Canada had better access to care than those in the U.S., but most of the differences were explained by differences in socioeconomic status (income, education) and insurance coverage across the two countries. However, immigrants in the U.S. were more likely to have timely Pap tests than immigrants in Canada.
Cato Institute
has expressed concerns that the U.S. government has restricted the freedom of Medicare patients to spend their own money on health care, and has contrasted these developments with the situation in Canada, where in 2005 the Supreme Court of Canada ruled that the province of Quebec could not prohibit its citizens from purchasing covered services through private health insurance. The institute has urged the Congress to restore the right of American seniors to spend their own money on medical care.
As reported by the Health Council of Canada
, a 2010 Commonwealth survey found that 42% of Canadians waited 2 hours or more in the emergency room, vs. 29% in the U.S.; 43% waited 4 weeks or more to see a specialist, vs. 10% in the U.S. The same survey states that 37% of Canadians say it is difficult to access care after hours (evenings, weekends or holidays) without going to the emergency department over 34% of Americans. Furthermore, 47% of Canadians, and 50% of Americans who visited emergency departments over the past two years feel that they could have been treated at their normal place of care if they were able to get an appointment.
A report published by Health Canada
in 2008 included statistics on self-reported wait times for diagnostic services. The median wait time for diagnostic services such as MRI and CAT scans is two weeks with 89.5% waiting less than 3 months. The median wait time to see a special physician is a little over four weeks with 86.4% waiting less than 3 months. The median wait time for surgery is a little over four weeks with 82.2% waiting less than 3 months. In the U.S., patients on Medicaid
, the low-income government programs, can wait three months or more to see specialists. Because Medicaid payments are low, some have claimed that some doctors do not want to see Medicaid patients. For example, in Benton Harbor, Michigan
, specialists agreed to spend one afternoon every week or two at a Medicaid clinic, which meant that Medicaid patients had to make appointments not at the doctor's office, but at the clinic, where appointments had to be booked months in advance. A 2009 study found that on average the wait in the United States to see a medical specialist is 20.5 days.
In a 2009 survey of physician appointment wait times in the United States, the average wait time for an appointment with an orthopaedic surgeon in country as a whole was 17 days. In Dallas, Texas the wait was 45 days (the longest wait being 365 days). Nationwide across the U.S. the average wait time to see a family doctor was 20 days. The average wait time to see a family practitioner in Los Angeles, California was 59 days and in Boston, Massachusetts it was 63 days.
Studies by the Commonwealth Fund
found that 42% of Canadians waited 2 hours or more in the emergency room, vs. 29% in the U.S.; 57% waited 4 weeks or more to see a specialist, vs. 23% in the U.S., but Canadians had more chances of getting medical attention at nights, or on weekends and holidays than their American neighbors without the need to visit an ER (54% compared to 61%). Statistics from the Canadian free market think tank Fraser Institute
in 2008 indicate that the average wait time between the time when a general practitioner refers a patient for care and the receipt of treatment was almost four and a half months in 2008, roughly double what it had been 15 years before.
A 2003 survey of hospital administrators conducted in Canada, the U.S., and three other countries found dissatisfaction with both the U.S. and Canadian systems. For example, 21% of Canadian hospital administrators, but less than 1% of American administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman; 50% of Canadian administrators versus none of their American counterparts said that it would take over six months for a 65-year-old to undergo a routine hip replacement surgery. However, U.S. administrators were the most negative about their country's health care system. Hospital executives in all five countries expressed concerns about staffing shortages and emergency department waiting times and quality.
In a letter to the Wall Street Journal, the President and CEO of University Health Network, Toronto, said that Michael Moore
's film Sicko
"exaggerated the performance of the Canadian health system — there is no doubt that too many patients still stay in our emergency departments waiting for admission to scarce hospital beds." However, "Canadians spend about 55% of what Americans spend on health care and have longer life expectancy, and lower infant mortality rates. Many Americans have access to quality health care. All Canadians have access to similar care at a considerably lower cost." There is "no question" that the lower cost has come at the cost of "restriction of supply with sub-optimal access to services," said Bell. A new approach is targeting waiting times, which are reported on public websites.
In 2007 Shona Holmes, a Waterdown, Ontario
woman who had a Rathke's cleft cyst
removed at the Mayo Clinic
, in Arizona, sued the Ontario government for failing to re-imburse her $95,000 in medical expenses.
Holmes had characterized her condition as an emergency, said she was losing her sight, and portrayed her condition as a life-threatening brain cancer.
In July 2009 Holmes agreed to appear in television ads broadcast in the United States warning Americans of the dangers of adopting a Canadian style health care system.
The ads she appeared in triggered debates on both sides of the border.
After her ad appeared critics pointed out discrepancies in her story, including that Rathke's cleft cyst
, the condition she was treated for, was not a form of cancer, and was not life-threatening.
A 1999 report found that after exclusions, administration accounted for 31.0% of health care expenditures in the United States, as compared with 16.7% of health care expenditures in Canada. In looking at the insurance element, in Canada, the provincial single-payer insurance system operated with overheads of 1.3%, comparing favourably with private insurance overheads (13.2%), U.S. private insurance overheads (11.7%) and U.S. Medicare and Medicaid program overheads (3.6% and 6.8% respectively). The report concluded by observing that gap between U.S. and Canadian spending on health care administration had grown to $752 per capita and that a large sum might be saved in the United States if the U.S. implemented a Canadian-style health care system.
However, U.S. government spending covers less than half of all health care costs. Private spending for health care is also far greater in the U.S. than in Canada. In Canada, an average of $917 was spent annually by individuals or private insurance companies for health care, including dental, eye care, and drugs. In the U.S., this sum is $3,372. In 2006, health care consumed 15.3% of U.S. annual GDP. In Canada, only 10% of GDP was spent on health care. This difference is a relatively recent development. In 1971 the nations were much closer, with Canada spending 7.1% of GDP on health while the U.S. spent 7.6%.
Some who advocate against greater government involvement in health care have asserted that the difference in health care costs between the two nations is partially explained by the differences in their demographics. Police-reported drug abuse
and violence
are more common in the United States than in Canada; both place a burden on the health care system. Illegal immigrants, more prevalent in the U.S. than in Canada, also add a burden to the health care system, as many of them do not carry health insurance and rely on emergency rooms — which are legally required to treat them — as a principal source of care. In Colorado, for example, an estimated 80% of illegal immigrants do not have health insurance.
The mixed system in the United States has become more similar to the Canadian system. In recent decades, managed care
has become prevalent in the United States, with some 90% of privately insured Americans belonging to plans with some form of managed care. In managed care, insurance companies control patients' health care to reduce costs, for instance by demanding a second opinion prior to some expensive treatments or by denying coverage for treatments not considered worth their cost.
Administrative costs for health care are also higher in the United States than in Canada.
, nurses, and other medical professionals. According to health data collected by the OECD, average income for physicians in the United States in 1996 was nearly twice that for physicians in Canada.
Canada has fewer doctors per capita than the United States. In the U.S, there were 2.4 doctors per 1,000 people in 2005; in Canada, there were 2.2. Some doctors leave Canada to pursue career goals or higher pay in the U.S., though significant numbers of physicians from countries such as India
, Pakistan
and South Africa
immigrate to practice in Canada. Many Canadian physicians and new medical graduates also go to the U.S. for post-graduate training in medical residencies. As it is a much larger market, new and cutting-edge sub-specialties are more widely available in the U.S. as opposed to Canada. However, statistics published in 2005 by the Canadian Institute for Health Information (CIHI), show that, for the first time since 1969 (the period for which data are available), more physicians returned to Canada than moved abroad.
has extended partial coverage for pharmaceuticals to Medicare beneficiaries. In Canada all drugs given in hospitals fall under Medicare, but other prescriptions do not. The provinces all have some programs to help the poor and seniors have access to drugs, but while there have been calls to create one, no national program exists. About two thirds of Canadians have private prescription drug coverage, mostly through their employers. In both countries, there is a significant population not fully covered by these programs. A 2005 study found that 20% of Canada's and 40% of America's sicker adults did not fill a prescription because of cost.
Furthermore, the 2010 Commonwealth Fund International Health Policy Survey indicates that 4% of Canadians indicated that they did not visit a doctor because of cost compared with 22% of Americans. Additionally, 21% of Americans have said that they did not fill a prescription for medicine or have skipped doses due to cost. That is compared with 10% of Canadians.
One of the most important differences between the two countries is the much higher cost of drugs in the United States. In the U.S., $728 per capita is spent each year on drugs, while in Canada it is $509. At the same time, consumption is higher in Canada, with about 12 prescriptions being filled per person each year in Canada and 10.6 in the United States. The main difference is that patented drug prices in Canada average between 35% and 45% lower than in the United States, though generic prices are higher. The price differential for brand-name drugs between the two countries has led Americans to purchase upward of $1 billion US in drugs per year from Canadian pharmacies.
There are several reasons for the disparity. The Canadian system takes advantage of centralized buying by the provincial governments that have more market heft and buy in bulk, lowering prices. By contrast, the U.S. has explicit laws that prohibit Medicare
or Medicaid
from negotiating drug prices. In addition, price negotiations by Canadian health insurers are based on evaluations of the clinical effectiveness of prescription drugs, allowing the relative prices of therapeutically-similar drugs to be considered in context. The Canadian Patented Medicine Prices Review Board also has the authority to set a fair and reasonable price on patented products, either comparing it to similar drugs already on the market, or by taking the average price in seven developed nations. Prices are also lowered through more limited patent protection in Canada. In the U.S., a drug patent may be extended five years to make up for time lost in development. Some generic drug
s are thus available on Canadian shelves sooner.
The pharmaceutical industry is important in both countries, though both are net importers of drugs. Both countries spend about the same amount of their GDP on pharmaceutical research, about 0.1% annually
scanners per million population while the U.S. had 19.5 per million. Canada's 10.3 CT scanners per million also ranked behind the U.S., which had 29.5 per million. The study did not attempt to assess whether the difference in the number of MRI and CT scanners had any effect on the medical outcomes or were a result of overcapacity but did observe that MRI scanners are used more intensively in Canada than either the U.S. or Great Britain. This disparity in the availability of technology, some believe, results in longer wait times. In 1984 wait times of up to 22 months for an MRI
were alleged in Saskatchewan. However, according to more recent official statistics (2007), all emergency patients receive MRIs within 24 hours, those classified as urgent receive them in under 3 weeks and the maximum elective wait time is 19 weeks in Regina and 26 weeks in Saskatoon, the province's two largest metropolitan areas.
According to the Health Council of Canada’s 2010 report "Decisions, Decisions: Family doctors as gatekeepers to prescription drugs and diagnostic imaging in Canada", the Canadian federal government invested $3 billion over 5 years (2000-2005) in relation to diagnostic imaging and agreed to invest a further $2 billion to reduce wait times. These investments led to an increase in the number of scanners across Canada as well as the number of exams being performed. The number of CT scanners increased from 198 to 465 and MRI scanners increased from 19 to 266 (more than tenfold) between 1990 and 2009. Similarly, the number of CT exams increased by 58% and MRI exams increased by 100% between 2003 and 2009. In comparison to other OECD countries, including the US, Canada’s rates of MRI and CT exams falls somewhere in the middle. Nevertheless, the Canadian Association of Radiologists claims that as many as 30% of diagnostic imaging scans are inappropriate and contribute no useful information.
lawsuits is a proportion of health spending in both the U.S. (0.46%) and Canada (0.27%). In Canada the total cost of settlements, legal fees, and insurance comes to $4 per person each year, but in the United States it is $16. Average payouts to American plaintiffs were $265,103, while payouts to Canadian plaintiffs were somewhat higher, averaging $309,417. However, malpractice suits are far more common in the U.S., with 350% more suits filed each year per person. While malpractice costs are significantly higher in the U.S., they make up only a small proportion of total medical spending. The total cost of defending and settling malpractice lawsuits in the U.S. in 2001 was approximately $6.5 billion, or 0.46% of total health spending. Critics say that defensive medicine
consumes up to 9% of American healthcare expenses. In the same year in Canada, the total burden of malpractice suits was $237 million, or 0.27% of total health spending.
According to American Medical News, eight states saw two or more liability insurers raise rates by at least 30 percent in 2001. In more than 12 states, one or more insurers raised rates by 25 percent or more.
"Across the country, liability insurance for obstetrician-gynecologists is becoming unaffordable or even unavailable," said ACOG President Thomas Purdon, MD.
The situation is particularly worrisome for rural areas, where physicians and care are often already in short supply. "Hospitals, public health clinics, and medical facilities in medically underserved areas begin to lose prenatal and delivery care. The impact on rural women and Medicaid patients is most acute," said Dr. Purdon.
, both by insurance companies and health care providers. These costs are higher in the U.S., contributing to higher overall costs in that nation.
among 191 member nations published in 2000, Canada ranked 30th and the U.S. 37th, while the overall health of Canadians was ranked 35th and Americans 72nd. However, the WHO's methodologies, which attempted to measure how efficiently health systems translate expenditure into health, generated broad debate and criticism.
Researchers caution against inferring health care quality from some health statistics. June O'Neill and Dave O'Neill point out that "...life expectancy and infant mortality are both poor measures of the efficacy of a health care system because they are influenced by many factors that are unrelated to the quality and accessibility of medical care".
In 2007, Gordon H. Guyatt et al. conducted a meta-analysis, or systematic review, of all studies that compared health outcomes for similar conditions in Canada and the U.S., in Open Medicine, an open-access peer-reviewed Canadian medical journal. They concluded, "Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Guyatt identified 38 studies addressing conditions including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies with the strongest statistical validity, 5 favoured Canada, 2 favoured the United States, and 3 were equivalent or mixed. Of 28 weaker studies, 9 favoured Canada, 3 favoured the United States, and 16 were equivalent or mixed. Overall, results for mortality favoured Canada with a 5% advantage, but the results were weak and varied. The only consistent pattern was that Canadian patients fared better in kidney failure.
Canadians are, overall, statistically healthier than Americans and show lower rates of many diseases such as various forms of cancer. On the other hand, evidence suggests that with respect to some illnesses (such as breast cancer), those who do get sick have a higher rate of cure in the U.S. than in Canada.
In terms of population health, life expectancy
in 2006 was about two and a half years longer in Canada, with Canadians living to an average of 79.9 years and Americans 77.5 years. Infant and child mortality rates are also higher in the U.S. Some comparisons suggest that the American system underperforms Canada's system as well as those of other industrialized nations with universal coverage. For example, a ranking by the World Health Organization of health care system performance among 191 member nations, published in 2000, ranked Canada 30th and the U.S. 37th, and the overall health of Canada 35th to the American 72nd. The WHO did not merely consider health care outcomes, but also placed heavy emphasis on the health disparities between rich and poor, funding for the health care needs of the poor, and the extent to which a country was reaching the potential health care outcomes they believed were possible for that nation. In an international comparison of 21 more specific quality indicators conducted by the Commonwealth Fund International Working Group on Quality Indicators, the results were more divided. One of the indicators was a tie, and in 3 others, data was unavailable from one country or the other. Canada performed better on 11 indicators; such as survival rates for colorectal cancer, childhood leukemia, and kidney and liver transplants. The U.S. performed better on 6 indicators, including survival rates for breast and cervical cancer, and avoidance of childhood diseases such as pertussis and measles. It should be noted that the 21 indicators were distilled from a starting list of 1000. The authors state that, "It is an opportunistic list, rather than a comprehensive list."
Some of the difference in outcomes may also be related to lifestyle choices. The OECD found that Americans have slightly higher rates of smoking and alcohol consumption than do Canadians as well as significantly higher rates of obesity
. A joint US-Canadian study found slightly higher smoking rates among Canadians. Another study found that Americans have higher rates not only of obesity, but also of other health risk factors and chronic conditions, including physical inactivity, diabetes, hypertension, arthritis, and chronic obstructive pulmonary disease.
While a Canadian systematic review
stated that the differences in the health care systems of Canada and the United States could not alone explain differences in health care outcomes, the study didn't consider that over 44,000 Americans die every year due to not having a single payer system for healthcare in the United States and it didn't consider the millions more that live without proper medical care due to a lack of insurance.
incidence and mortality in Canada and the U.S., with varying results. Doctors who study cancer epidemiology warn that the diagnosis of cancer is subjective, and the reported incidence of a cancer will rise if screening is more aggressive, even if the real cancer incidence is the same. Statistics from different sources may not be compatible if they were collected in different ways. The proper interpretation of cancer statistics has been an important issue for many years. Dr. Barry Kramer of the National Institutes of Health
points to the fact that cancer incidence rose sharply over the past few decades as screening became more common. He attributes the rise to increased detection of benign early stage cancers that pose little risk of metastasizing. Furthermore, though patients who were treated for these benign cancers were at little risk, they often have trouble finding health insurance after the fact.
Cancer survival time increases with later years of diagnosis, because cancer treatment improves, so cancer survival statistics can only be compared for cohorts in the same diagnosis year. For example, as doctors in British Columbia adopted new treatments, survival time for patients with metastatic breast cancer increased from 438 days for those diagnosed in 1991–1992, to 667 days for those diagnosed in 1999–2001.
An assessment by Health Canada
found that cancer mortality rates are almost identical in the two countries. Another international comparison by the National Cancer Institute of Canada indicated that incidence rates for most, but not all, cancers were higher in the U.S. than in Canada during the period studied (1993–1997). Incidence rates for certain types, such as colorectal and stomach cancer, were actually higher in Canada than in the U.S. In 2004, researchers published a study comparing health outcomes in the Anglo countries. Their analysis indicates that Canada has greater survival rates for both colorectal cancer and childhood leukemia, while the United States has greater survival rates for Non-Hodgkin's lymphoma as well as breast and cervical cancer.
A study based on data from 1978 through 1986 found very similar survival rates in both the United States and in Canada. However, a study based on data from 1993 through 1997 found lower cancer survival rates among Canadians than among Americans.
A few comparative studies have found that cancer survival rates vary more widely among different populations in the U.S. than they do in Canada. Mackillop and colleagues compared cancer survival rates in Ontario and the U.S. They found that cancer survival was more strongly correlated with socio-economic class in the U.S. than in Ontario. Furthermore, they found that the American survival advantage in the four highest quintiles was statistically significant. They strongly suspected that the difference due to prostate cancer was a result of greater detection of asymptomatic cases in the U.S. Their data indicates that neglecting the prostate cancer data reduces the American advantage in the four highest quintiles and gives Canada a statistically significant advantage in the lowest quintile. Similarly, they believe differences in screening mammography may explain part of the American advantage in breast cancer. Exclusion of breast and prostate cancer data results in very similar survival rates for both countries.
Hsing et al. found that prostate cancer mortality incidence rate ratios were lower among U.S. whites than among any of the nationalities included in their study, including Canadians. U.S. blacks in the study had lower rates than any group except for Canadians and U.S. whites. Echoing the concerns of Dr. Kramer and Professor Mackillop, Hsing later wrote that reported prostate cancer incidence depends on screening. Among whites in the U.S., the death rate for prostate cancer remained constant, even though the incidence increased, so the additional reported prostate cancers did not represent an increase in real prostate cancers, said Hsing. Similarly, the death rates from prostate cancer in the U.S. increased during the 1980s and peaked in early 1990. This is at least partially due to "attribution bias" on death certificates, where doctors are more likely to ascribe a death to prostate cancer than to other diseases that affected the patient, because of greater awareness of prostate cancer or other reasons.
Because health status is "considerably affected" by socioeconomic and demographic characteristics, such as level of education and income, "the value of comparisons in isolating the impact of the health care system on outcomes is limited," according to health care analysts. Experts say that the incidence and mortality rates of cancer cannot be combined to calculate survival from cancer. Nevertheless, researchers have used the ratio of mortality to incidence rates as one measure of the effectiveness of health care. Data for both studies was collected from registries that are members of the North American Association of Central Cancer Registries
, an organization dedicated to developing and promoting uniform data standards for cancer registration in North America.
peoples constitute a much larger proportion of the Canadian population. Canada also has a proportionally larger South Asian and East Asian population. Also, the proportion of each population that is immigrant is higher in Canada.
A study comparing aboriginal mortality rates in Canada, the U.S. and New Zealand found that aboriginals in all three countries had greater mortality rates and shorter life expectancies than the white majorities. That study also found that aboriginals in Canada had both shorter life expectancies and greater infant mortality rates than aboriginals in the United States and New Zealand. The health outcome differences between aboriginals and whites in Canada was also larger than in the United States.
Though few studies have been published concerning the health of Black Canadians, health disparities between whites and blacks in the U.S. have received intense scrutiny. Blacks in the U.S. have significantly greater rates of cancer incidence and mortality. Drs. Singh and Yu found that neonatal and postnatal mortality rates for American blacks are more than double the non-Hispanic white rate. This difference persisted even after controlling for household income and was greatest in the highest income quintile. A Canadian study also found differences in neonatal mortality between different racial and ethnic groups. Although Canadians of African descent had a greater mortality rate than whites in that study, the rate was somewhat less than double the white rate.
The racially heterogeneous Hispanic population in the U.S. has also been the subject of several studies. Although members of this group are significantly more likely to live in poverty than are non-Hispanic whites, they often have disease rates that are comparable to or better than the non-Hispanic white majority. Hispanics have lower cancer incidence and mortality, lower infant mortality, and lower rates of neural tube defects. Singh and Yu found that infant mortality among Hispanic sub-groups varied with the racial composition of that group. The mostly white Cuban population had a neonatal mortality rate (NMR) nearly identical to that found in non-Hispanic whites and a postnatal mortality rate (PMR) that was somewhat lower. The largely Mestizo
, Mexican, Central, and South American Hispanic populations had somewhat lower NMR and PMR. Puerto Ricans who often have a mix of white and African ancestry had higher NMR and PMR rates.
$5.8 billion, and increased to $7 billion. The UAW
also claimed that the resulting escalating health care premiums reduced workers' bargaining powers.
Since 1998, Canada's successive multi-billion dollar budget surpluses have allowed a significant injection of new funding to the healthcare system, with the stated goal of reducing waiting times for treatment. However, this may be hampered by the return to deficit spending as of the 2009 Canadian federal budget
.
One historical problem with the U.S. system was known as job lock
, in which people become tied to their jobs for fear of losing their health insurance. This reduces the flexibility of the labor market. Federal legislation passed since the mid-1980s, particularly COBRA
and HIPAA
, has been aimed at reducing job lock. However, providers of group health insurance in many states are permitted to use experience rating
and it remains legal in the United States for prospective employers to investigate a job candidate's health and past health claims as part of a hiring decision. Someone who has recently been diagnosed with cancer, for example, may face job lock
not out of fear of losing their health insurance, but based on prospective employers not wanting to add the cost of treating that illness to their own health insurance pool, for fear of future insurance rate increases. Thus, being diagnosed with an illness can cause someone to be forced to stay in their current job.
and its successor, the Conservative Party of Canada
considered increasing the role of the private sector in the Canadian health care system. Public backlash caused these plans to be abandoned, and the current majority Conservative government has re-affirmed its commitment to universal public medicine.
In Canada, it was Alberta
under the Conservative government that has experimented most with increasing the role of the private sector in health care. Measures have included the introduction of private clinics that are allowed to bill patients for some of the cost of a procedure.
attempted a significant restructuring of health care
, but the effort collapsed under public pressure against it. The 2000 U.S. election saw prescription drug
s become a central issue, although the system did not fundamentally change. In the 2004 U.S. election health care proved to be an important issue to some voters, though not a primary one.
In 2006, Massachusetts
adopted a plan that vastly reduced the number of uninsured making it the state with the lowest percentage of non-insured residents in the union. It requires everyone to buy insurance and subsidizes insurance costs for lower income people on a sliding scale. Some have claimed that the state's program is unaffordable, which the state itself says is "a commonly repeated myth". In 2009, in a minor amendment, the plan did eliminate dental, hospice and skilled nursing care for certain categories of non citizens covering 30,000 people (victims of human trafficking and domestic violence, applicants for asylum and refugees) who do pay taxes.
In July 2009, Connecticut
passed into law a plan called SustiNet
, with the goal of achieving health-care coverage of 98% of its residents by 2014.
, waiting list delays "increase the patient’s risk of mortality or the risk that his or her injuries will become irreparable." The ruling found that a Quebec provincial ban on private health insurance was unlawful, because it was contrary to Quebec's own legislative act, the 1975 Charter of Human Rights and Freedoms.
. By that they mean Health Savings Accounts (HSAs), which were created by the Medicare bill signed by President Bush on December 8, 2003. HSAs are designed to provide tax incentives for individuals to save for future qualified medical and retiree health expenses; the money placed in such accounts is tax-free. To qualify for these tax-deferred accounts, individuals must carry a High Deductible Health Plan
(HDHP). The higher deductible shifts some of the financial responsibility for health care from insurance providers to the individual consumer. This shift towards a market-based system with greater individual responsibility may increase the differences between the U.S. and Canadian systems. Some economists who have studied various proposals for universal health care are concerned that the main effect of the consumer driven healthcare movement will be to reduce the social redistributive effects of insurance that pools high-risk and low-risk people together. In an attempt to reverse that Democrats have passed legislation that Beginning January 1, 2011, as a result of Health Care Reform, also known as Patient Protection and Affordable Care Act, HSA funds can no longer be used to buy over-the-counter drugs without a doctor's prescription.
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...
and public policy analysts. The two countries had similar health care system
Health care system
A health care system is the organization of people, institutions, and resources to deliver health care services to meet the health needs of target populations....
s before Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
reformed its system in the 1960s and 1970s. The United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
spends much more money on health care than Canada, on both a per-capita basis and as a percentage of GDP. In 2006, per-capita spending for health care in Canada was US$3,678; in the U.S., US$6,714. The U.S. spent 15.3% of GDP on health care in that year; Canada spent 10.0%. In 2006, 70% of health care spending in Canada was financed by government, versus 46% in the United States. Total government spending per capita in the U.S. on health care was 23% higher than Canadian government spending, and U.S. government expenditure on health care was just under 83% of total Canadian spending (public and private) though these statistics don't take into account population differences.
Studies have come to different conclusions about the result of this disparity in spending. A 2007 review of all studies comparing health outcomes in Canada and the US in a Canadian peer-reviewed medical journal found that "health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Life expectancy is longer in Canada, and its infant mortality rate is lower than that of the U.S., but there is debate about the underlying causes of these differences. One commonly-cited comparison, the 2000 World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
's ratings of "overall health service performance", which used a "composite measure of achievement in the level of health, the distribution of health, the level of responsiveness and fairness of financial contribution", ranked Canada 30th and the U.S. 37th among 191 member nations. This study rated the US "responsiveness", or quality of service for individuals receiving treatment, as 1st, compared with 7th for Canada. However, the average life expectancy for Canadians was 80.34 years compared with 78.6 years for residents of the U.S.
A 2004 study found that Canada had a slightly higher mortality rate for acute myocardial infarction (Heart Attack) because of the more conservative Canadian approach to revascularizing (opening) coronary arteries.
The WHO's study methods were criticized by some analyses.
Although there is a measure of consensus that life-expectancy and infant mortality mark the most reliable ways to compare nation-wide health care, a recent report by the Congressional Research Service
Congressional Research Service
The Congressional Research Service , known as "Congress's think tank", is the public policy research arm of the United States Congress. As a legislative branch agency within the Library of Congress, CRS works exclusively and directly for Members of Congress, their Committees and staff on a...
carefully summarizes some recent data and notes the "difficult research issues" facing international comparisons.
The health care system in Canada
Health care in Canada
Health care in Canada is delivered through a publicly-funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act. The government assures the quality of care through federal standards...
is funded by a mix of public (70%) and private (30%) funding, with most end-services delivered by private providers.
Through all entities in its public-private system
Health care in the United States
Health care in the United States is provided by many separate legal entities. Health care facilities are largely owned and operated by the private sector...
, the U.S. spends more per capita than any other nation in the world, but is the only wealthy industrialized country in the world that lacks some form of universal health care
Universal health care
Universal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...
. In March 2010, the US Congress passed regulatory reform of the American health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
system. However since this legislation is not fundamental health care
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
reform, it is unclear what its effect will be and as the new legislation is implemented in stages, with the last provision in effect in 2018, it will be some years before any empirical evaluation of the full effects on the comparison could be determined.
Health care costs in both countries are rising faster than inflation. As both countries consider changes to their systems, there is debate over whether resources should be added to the public or private sector. Although Canadians and Americans have each looked to the other for ways to improve their respective health care systems, there exists a substantial amount of conflicting information regarding the relative merits of the two systems. In Canada, the United States is used as a model and/or as a warning against increasing private sector involvement in financing health care. In the U.S., meanwhile, Canada's mostly monopsonistic
Monopsony
In economics, a monopsony is a market form in which only one buyer faces many sellers. It is an example of imperfect competition, similar to a monopoly, in which only one seller faces many buyers...
health system is seen by different sides of the ideological spectrum as either a model to be followed or avoided.
Government involvement
In 2004, government funding of health care in Canada was equivalent to [US$] 1,893 per person. In the U.S. government spending per person was US$ 2,728.It is important to note that the Canadian healthcare system is actually composed of at least 10 mostly autonomous provincial healthcare systems, and a federal system which covers veterans. This causes a significant degree of variation in funding and coverage within the country.
Canada and the United States had similar health care systems in the early 1960s, but now have a different mix of funding mechanisms. Canada's universal single-payer health care
Single-payer health care
Single-payer health care is medical care funded from a single insurance pool, run by the state. Under a single-payer system, universal health care for an entire population can be financed from a pool to which many parties employees, employers, and the state have contributed...
system covers about 70% of expenditures, and the Canada Health Act
Canada Health Act
The Canada Health Act is a piece of Canadian federal legislation, adopted in 1984, which specifies the conditions and criteria with which the provincial and territorial health insurance programs must conform in order to receive federal transfer payments under the Canada Health Transfer...
requires that all insured persons be fully insured, without co-payments or user fees, for all medically necessary hospital and physician care. About 91% of hospital expenditures and 99% of total physician services are financed by the public sector. Ophthalmology and dental services account for a lot of the private expenditures in Canada. In the United States, with its mixed public-private system, 16% or 45 million American residents are uninsured at any one time. The U.S. is one of two OECD countries not to have some form of universal health coverage, the other being Turkey. Mexico established a universal healthcare program by November 2008.
The governments of both nations are closely involved in health care. The central structural difference between the two is in health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
. In Canada, the federal government is committed to providing funding support to its provincial governments for health care expenditures as long as the province in question abides by accessibility guarantees as set out in the Canada Health Act
Canada Health Act
The Canada Health Act is a piece of Canadian federal legislation, adopted in 1984, which specifies the conditions and criteria with which the provincial and territorial health insurance programs must conform in order to receive federal transfer payments under the Canada Health Transfer...
, which explicitly prohibits billing end users for procedures that are covered by Medicare
Medicare (Canada)
Medicare is the unofficial name for Canada's publicly funded universal health insurance system. The formal terminology for the insurance system is provided by the Canada Health Act and the health insurance legislation of the individual provinces and territories.Under the terms of the Canada Health...
. While some label Canada's system as "socialized medicine," the term is inaccurate. Unlike systems with public delivery, such as the UK, the Canadian system provides public coverage for private delivery. As Princeton University health economist Uwe E. Reinhardt notes, single-payer systems are not "socialized medicine" but "social insurance" systems, because doctors are in the private sector. Similarly, Canadian hospitals are controlled by private boards and/or regional health authorities, rather than being part of government.
In the U.S., direct government funding of health care is limited to Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
, Medicaid
Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
, and the State Children's Health Insurance Program
State Children's Health Insurance Program
The State Children's Health Insurance Program – later known more simply as the Children's Health Insurance Program – is a program administered by the United States Department of Health and Human Services that provides matching funds to states for health insurance to families with children...
(SCHIP), which cover eligible senior citizens, the very poor, disabled persons, and children. The federal government also runs the Veterans Administration
United States Department of Veterans Affairs
The United States Department of Veterans Affairs is a government-run military veteran benefit system with Cabinet-level status. It is the United States government’s second largest department, after the United States Department of Defense...
, which provides care to veterans, their families, and survivors through medical centers and clinics.
The U.S. government also runs the Military Health System. In Fiscal Year 2007, the MHS had total budget authority of $39.4 billion and served approximately 9.1 million beneficiaries, including Active Duty personnel and their families and retirees and their families. The MHS includes 133,000 personnel, 86,000 military and 47,000 civilian, working at more than 1,000 locations worldwide, including 70 inpatient facilities and 1,085 medical, dental, and veterinary clinics.
One study estimates that about 25 percent of the uninsured in the U.S. are eligible for these programs but remain unenrolled; however, extending coverage to all who are eligible remains a fiscal and political challenge.
For everyone else, health insurance must be paid for privately. Some 59% of U.S. residents have access to health care insurance through employers, although this figure is decreasing, and coverages as well as workers' expected contributions vary widely. Those whose employers do not offer health insurance, as well as those who are self-employed or unemployed, must purchase it on their own. Nearly 27 million of the 45 million uninsured U.S. residents worked at least part-time in 2007, and more than a third were in households that earned $50,000 or more per year.
Despite the greater role of private business in the U.S., federal and state agencies are increasingly involved in U.S. health care spending, paying about 45% of the $2.2 trillion the nation spent on medical care in 2004. The U.S. government spends more on health care than on Social Security and national defense combined, according to the Brookings Institution
Brookings Institution
The Brookings Institution is a nonprofit public policy organization based in Washington, D.C., in the United States. One of Washington's oldest think tanks, Brookings conducts research and education in the social sciences, primarily in economics, metropolitan policy, governance, foreign policy, and...
.
Beyond its direct spending, the U.S. government is also highly involved in health care through regulation and legislation. For example, the Health Maintenance Organization Act of 1973
Health Maintenance Organization Act of 1973
The Health Maintenance Organization Act of 1973 , also known as the HMO Act of 1973, 42 U.S.C. § 300e, is a law passed by the Congress of the United States that resulted from discussions Paul Ellwood had with what is today the Department of Health and Human Services...
provided grants and loans to subsidize Health Maintenance Organizations and contained provisions to stimulate their popularity. HMOs had been declining before the law; by 2002 there were 500 such plans enrolling 76 million people.
The Canadian system has been 69–75% publicly funded, though most services are delivered by private providers, including physicians (although they may derive their revenue primarily from government billings). Although some doctors work on a purely fee-for-service basis (usually family physicians), some family physicians and most specialists are paid through a combination of fee-for-service and fixed contracts with hospitals or health service management organizations.
Canada's universal health plan does not cover certain services. Non-cosmetic dental care
Dentistry
Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...
is covered for children up to age 14 in some provinces. Outpatient prescription drugs are not required to be covered, but some provinces have drug cost programs that cover most drug costs for certain populations. In every province, seniors receiving the Guaranteed Income Supplement have significant additional coverage; some provinces expand forms of drug coverage to all seniors, low-income families, those on social assistance, or those with certain medical conditions. Some provinces cover all drug prescriptions over a certain portion of a family's income. Drug prices are also regulated, so brand-name prescription drugs are often significantly cheaper than in the U.S. Optometry
Optometry
Optometry is a health care profession concerned with eyes and related structures, as well as vision, visual systems, and vision information processing in humans. Optometrists, or Doctors of Optometry, are state licensed medical professionals trained to prescribe and fit lenses to improve vision,...
is only covered in some provinces and is sometimes only covered for children under a certain age. Visits to non-physician specialists may require an additional fee. Also, some procedures are only covered under certain circumstances. For example, circumcision
Circumcision
Male circumcision is the surgical removal of some or all of the foreskin from the penis. The word "circumcision" comes from Latin and ....
is not covered, and a fee is usually charged when a parent requests the procedure; however, if an infection or medical necessity
Medical necessity
Medical necessity is a United States legal doctrine, related to activities which may be justified as reasonable, necessary, and/or appropriate, based on evidence-based clinical standards of care. Other countries may have medical doctrines or legal rules covering broadly similar grounds...
arises, the procedure would be covered.
According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly.
"Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics …The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization."
Coverage and access
In both Canada and the United States, access to health care can be a problem. Studies suggest that 40% of U.S. citizens do not have adequate health insurance, if any at all. In Canada, however, as many as 5% of Canadian citizens have not been able to find a regular doctor, with a further 9% having never looked for one. Yet, even if some cannot find a family doctor, every Canadian citizen is covered by the national health care system. The U.S. data is evidenced in a 2007 Consumer Reports study on the U.S. health care system which showed that the underinsured account for 24% of the U.S. population and live with skeletal health insurance that barely covers their medical needs and leaves them unprepared to pay for major medical expenses. When added to the population of uninsured (approximately 16% of the U.S. population), a total of 40% of Americans ages 18–64 have inadequate access to health care, according to the Consumer Reports study. The Canadian data comes from the 2003 Canadian Community Health Survey,In the U.S., the federal government does not guarantee universal health care
Universal health care
Universal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...
to all its citizens, but publicly funded health care programs help to provide for the elderly, disabled, the poor, and children. The Emergency Medical Treatment and Active Labor Act
Emergency Medical Treatment and Active Labor Act
The Emergency Medical Treatment and Active Labor Act is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act . It requires hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to...
or EMTALA also ensures public access to emergency services. The EMTALA law forces emergency health care providers to stabilize an emergency health crisis and cannot withhold treatment for lack of evidence of insurance coverage or other evidence of the ability to pay. EMTALA does not absolve the person receiving emergency care of the obligation to meet the cost of emergency health care not paid for at the time and it is still within the right of the hospital to pursue any debtor for the cost of emergency health care provided. In Canada, emergency room treatment for legal Canadian residents is not charged to the patient at time of service but is met by the government.
According to the United States Census Bureau
United States Census Bureau
The United States Census Bureau is the government agency that is responsible for the United States Census. It also gathers other national demographic and economic data...
, 59.3% of U.S. citizens have health insurance
Health insurance
Health insurance is insurance against the risk of incurring medical expenses among individuals. By estimating the overall risk of health care expenses among a targeted group, an insurer can develop a routine finance structure, such as a monthly premium or payroll tax, to ensure that money is...
related to employment, 27.8% have government-provided health-insurance; nearly 9% purchase health insurance directly (there is some overlap in these figures), and 15.3% (45.7 million) were uninsured in 2007. An estimated 25 percent of the uninsured are eligible for government programs but unenrolled. About a third of the uninsured are in households earning more than $50,000 annually. A 2003 report by the Congressional Budget Office found that many people lack health insurance only temporarily, such as after leaving one employer and before a new job. The number of chronically uninsured (uninsured all year) was estimated at between 21 and 31 million in 1998. Another study, by the Kaiser Commission on Medicaid and the Uninsured, estimated that 59 percent of uninsured adults have been uninsured for at least two years. One indicator of the consequences of Americans' inconsistent health care coverage is a study in Health Affairs that concluded that half of personal bankruptcies involved medical bills. Although other sources dispute this, it is possible that medical debt
Medical debt
Medical debt refers to debt incurred by individuals due to health care costs and related expenses.Medical debt is different from other forms of debt, because it is usually incurred accidentally or faultlessly...
is the principal cause of bankruptcy in the United States
Bankruptcy in the United States
Bankruptcy in the United States is governed under the United States Constitution which authorizes Congress to enact "uniform Laws on the subject of Bankruptcies throughout the United States." Congress has exercised this authority several times since 1801, most recently by adopting the Bankruptcy...
.
A number of clinics
Free clinic
A free clinic is a medical facility offering community healthcare on a free or very low-cost basis in countries with marginal or no universal health care. Care is generally provided in these clinics to persons who have lower or limited income and no health insurance, including persons who are not...
provide free or low-cost non-emergency care to poor, uninsured patients. The National Association of Free Clinics claims that its member clinics provide $3 billion in services to some 3.5 million patients annually.
A peer-reviewed comparison study of health care access in the two countries published in 2006 concluded that U.S. residents are one third less likely to have a regular medical doctor, one fourth more likely to have unmet health care needs, and are more than twice as likely to forgo needed medicines. The study noted that access problems "were particularly dire for the US uninsured." Those who lack insurance in the U.S. were much less satisfied, less likely to have seen a doctor, and more likely to have been unable to receive desired care than both Canadians and insured Americans.
Another cross-country study compared access to care based on immigrant status in Canada and the U.S. Findings showed that in both countries, immigrants had worse access to care than non-immigrants. Specifically, immigrants living in Canada were less likely to have timely Pap tests compared with native-born Canadians; in addition, immigrants in the U.S. were less likely to have a regular medical doctor and an annual consultation with a health care provider compared with native-born Americans. In general, immigrants in Canada had better access to care than those in the U.S., but most of the differences were explained by differences in socioeconomic status (income, education) and insurance coverage across the two countries. However, immigrants in the U.S. were more likely to have timely Pap tests than immigrants in Canada.
Cato Institute
Cato Institute
The Cato Institute is a libertarian think tank headquartered in Washington, D.C. It was founded in 1977 by Edward H. Crane, who remains president and CEO, and Charles Koch, chairman of the board and chief executive officer of the conglomerate Koch Industries, Inc., the largest privately held...
has expressed concerns that the U.S. government has restricted the freedom of Medicare patients to spend their own money on health care, and has contrasted these developments with the situation in Canada, where in 2005 the Supreme Court of Canada ruled that the province of Quebec could not prohibit its citizens from purchasing covered services through private health insurance. The institute has urged the Congress to restore the right of American seniors to spend their own money on medical care.
Wait times
One complaint about both the U.S. and Canadian health care systems is waiting times, whether for a specialist, major elective surgery, such as hip replacement, or specialized treatments, such as radiation for breast cancer; wait times in each country are affected by various factors. In the United States, access to health care is primarily determined by whether a person has access to funding to pay for treatment and by the availability of services in the area and by willingness of the provider to deliver service at the price set by the insurer. In Canada the wait time is set according the availability of services in the area and by the relative need of the person needing treatment.As reported by the Health Council of Canada
Health Council of Canada
The Health Council of Canada is a national, independent, nonprofit organization funded by Health Canada and mandated to monitor and report on the progress of health care renewal in Canada.- History :...
, a 2010 Commonwealth survey found that 42% of Canadians waited 2 hours or more in the emergency room, vs. 29% in the U.S.; 43% waited 4 weeks or more to see a specialist, vs. 10% in the U.S. The same survey states that 37% of Canadians say it is difficult to access care after hours (evenings, weekends or holidays) without going to the emergency department over 34% of Americans. Furthermore, 47% of Canadians, and 50% of Americans who visited emergency departments over the past two years feel that they could have been treated at their normal place of care if they were able to get an appointment.
A report published by Health Canada
Health Canada
Health Canada is the department of the government of Canada with responsibility for national public health.The current Minister of Health is Leona Aglukkaq, a Conservative Member of Parliament appointed to the position by Prime Minister Stephen Harper.-Branches, regions and agencies:Health Canada...
in 2008 included statistics on self-reported wait times for diagnostic services. The median wait time for diagnostic services such as MRI and CAT scans is two weeks with 89.5% waiting less than 3 months. The median wait time to see a special physician is a little over four weeks with 86.4% waiting less than 3 months. The median wait time for surgery is a little over four weeks with 82.2% waiting less than 3 months. In the U.S., patients on Medicaid
Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
, the low-income government programs, can wait three months or more to see specialists. Because Medicaid payments are low, some have claimed that some doctors do not want to see Medicaid patients. For example, in Benton Harbor, Michigan
Benton Harbor, Michigan
Benton Harbor is a city in Berrien County in the U.S. state of Michigan which is located west of Kalamazoo. The population was 10,038 at the 2010 census. It is the lesser populated of the two principal cities included in the Niles-Benton Harbor, Michigan Metropolitan Statistical Area, which has a...
, specialists agreed to spend one afternoon every week or two at a Medicaid clinic, which meant that Medicaid patients had to make appointments not at the doctor's office, but at the clinic, where appointments had to be booked months in advance. A 2009 study found that on average the wait in the United States to see a medical specialist is 20.5 days.
In a 2009 survey of physician appointment wait times in the United States, the average wait time for an appointment with an orthopaedic surgeon in country as a whole was 17 days. In Dallas, Texas the wait was 45 days (the longest wait being 365 days). Nationwide across the U.S. the average wait time to see a family doctor was 20 days. The average wait time to see a family practitioner in Los Angeles, California was 59 days and in Boston, Massachusetts it was 63 days.
Studies by the Commonwealth Fund
Commonwealth Fund
The Commonwealth Fund is a private U.S. foundation whose stated purpose is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, especially for society's most vulnerable.-History:...
found that 42% of Canadians waited 2 hours or more in the emergency room, vs. 29% in the U.S.; 57% waited 4 weeks or more to see a specialist, vs. 23% in the U.S., but Canadians had more chances of getting medical attention at nights, or on weekends and holidays than their American neighbors without the need to visit an ER (54% compared to 61%). Statistics from the Canadian free market think tank Fraser Institute
Fraser Institute
The Fraser Institute is a Canadian think tank. It has been described as politically conservative and right-wing libertarian and espouses free market principles...
in 2008 indicate that the average wait time between the time when a general practitioner refers a patient for care and the receipt of treatment was almost four and a half months in 2008, roughly double what it had been 15 years before.
A 2003 survey of hospital administrators conducted in Canada, the U.S., and three other countries found dissatisfaction with both the U.S. and Canadian systems. For example, 21% of Canadian hospital administrators, but less than 1% of American administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman; 50% of Canadian administrators versus none of their American counterparts said that it would take over six months for a 65-year-old to undergo a routine hip replacement surgery. However, U.S. administrators were the most negative about their country's health care system. Hospital executives in all five countries expressed concerns about staffing shortages and emergency department waiting times and quality.
In a letter to the Wall Street Journal, the President and CEO of University Health Network, Toronto, said that Michael Moore
Michael Moore
Michael Francis Moore is an American filmmaker, author, social critic and activist. He is the director and producer of Fahrenheit 9/11, which is the highest-grossing documentary of all time. His films Bowling for Columbine and Sicko also place in the top ten highest-grossing documentaries...
's film Sicko
Sicko
Sicko is a 2007 documentary film by American filmmaker Michael Moore. The film investigates health care in the United States, focusing on its health insurance and the pharmaceutical industry. The movie compares the for-profit, non-universal U.S...
"exaggerated the performance of the Canadian health system — there is no doubt that too many patients still stay in our emergency departments waiting for admission to scarce hospital beds." However, "Canadians spend about 55% of what Americans spend on health care and have longer life expectancy, and lower infant mortality rates. Many Americans have access to quality health care. All Canadians have access to similar care at a considerably lower cost." There is "no question" that the lower cost has come at the cost of "restriction of supply with sub-optimal access to services," said Bell. A new approach is targeting waiting times, which are reported on public websites.
In 2007 Shona Holmes, a Waterdown, Ontario
Waterdown, Ontario
Waterdown is a town in Canada which since 2001 has been a community of Hamilton, Ontario.On January 1, 2001 the new city of Hamilton was formed from the amalgamation of the Regional Municipality of Hamilton-Wentworth and its six municipalities: Hamilton, Ancaster, Dundas, Flamborough, Glanbrook,...
woman who had a Rathke's cleft cyst
Rathke's cleft cyst
A Rathke's cleft cyst is a benign growth found on the pituitary gland in the brain, specifically a fluid-filled cyst in the posterior portion of the anterior pituitary gland...
removed at the Mayo Clinic
Mayo Clinic
Mayo Clinic is a not-for-profit medical practice and medical research group specializing in treating difficult patients . Patients are referred to Mayo Clinic from across the U.S. and the world, and it is known for innovative and effective treatments. Mayo Clinic is known for being at the top of...
, in Arizona, sued the Ontario government for failing to re-imburse her $95,000 in medical expenses.
Holmes had characterized her condition as an emergency, said she was losing her sight, and portrayed her condition as a life-threatening brain cancer.
In July 2009 Holmes agreed to appear in television ads broadcast in the United States warning Americans of the dangers of adopting a Canadian style health care system.
The ads she appeared in triggered debates on both sides of the border.
After her ad appeared critics pointed out discrepancies in her story, including that Rathke's cleft cyst
Rathke's cleft cyst
A Rathke's cleft cyst is a benign growth found on the pituitary gland in the brain, specifically a fluid-filled cyst in the posterior portion of the anterior pituitary gland...
, the condition she was treated for, was not a form of cancer, and was not life-threatening.
Price of health care and administration overheads
Health care is one of the most expensive items of both nations’ budgets. In the United States, the various levels of government spend more per capita on health care than levels of government do in Canada. In 2004, Canada government-spending was $2,120 (in US dollars) per person on health care, while the United States government-spending $2,724.A 1999 report found that after exclusions, administration accounted for 31.0% of health care expenditures in the United States, as compared with 16.7% of health care expenditures in Canada. In looking at the insurance element, in Canada, the provincial single-payer insurance system operated with overheads of 1.3%, comparing favourably with private insurance overheads (13.2%), U.S. private insurance overheads (11.7%) and U.S. Medicare and Medicaid program overheads (3.6% and 6.8% respectively). The report concluded by observing that gap between U.S. and Canadian spending on health care administration had grown to $752 per capita and that a large sum might be saved in the United States if the U.S. implemented a Canadian-style health care system.
However, U.S. government spending covers less than half of all health care costs. Private spending for health care is also far greater in the U.S. than in Canada. In Canada, an average of $917 was spent annually by individuals or private insurance companies for health care, including dental, eye care, and drugs. In the U.S., this sum is $3,372. In 2006, health care consumed 15.3% of U.S. annual GDP. In Canada, only 10% of GDP was spent on health care. This difference is a relatively recent development. In 1971 the nations were much closer, with Canada spending 7.1% of GDP on health while the U.S. spent 7.6%.
Some who advocate against greater government involvement in health care have asserted that the difference in health care costs between the two nations is partially explained by the differences in their demographics. Police-reported drug abuse
Drug abuse
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts...
and violence
Violence
Violence is the use of physical force to apply a state to others contrary to their wishes. violence, while often a stand-alone issue, is often the culmination of other kinds of conflict, e.g...
are more common in the United States than in Canada; both place a burden on the health care system. Illegal immigrants, more prevalent in the U.S. than in Canada, also add a burden to the health care system, as many of them do not carry health insurance and rely on emergency rooms — which are legally required to treat them — as a principal source of care. In Colorado, for example, an estimated 80% of illegal immigrants do not have health insurance.
The mixed system in the United States has become more similar to the Canadian system. In recent decades, managed care
Managed care
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
has become prevalent in the United States, with some 90% of privately insured Americans belonging to plans with some form of managed care. In managed care, insurance companies control patients' health care to reduce costs, for instance by demanding a second opinion prior to some expensive treatments or by denying coverage for treatments not considered worth their cost.
Administrative costs for health care are also higher in the United States than in Canada.
Medical professionals
Some of the extra money spent in the United States goes to doctorsPhysician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
, nurses, and other medical professionals. According to health data collected by the OECD, average income for physicians in the United States in 1996 was nearly twice that for physicians in Canada.
Canada has fewer doctors per capita than the United States. In the U.S, there were 2.4 doctors per 1,000 people in 2005; in Canada, there were 2.2. Some doctors leave Canada to pursue career goals or higher pay in the U.S., though significant numbers of physicians from countries such as India
India
India , officially the Republic of India , is a country in South Asia. It is the seventh-largest country by geographical area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world...
, Pakistan
Pakistan
Pakistan , officially the Islamic Republic of Pakistan is a sovereign state in South Asia. It has a coastline along the Arabian Sea and the Gulf of Oman in the south and is bordered by Afghanistan and Iran in the west, India in the east and China in the far northeast. In the north, Tajikistan...
and South Africa
South Africa
The Republic of South Africa is a country in southern Africa. Located at the southern tip of Africa, it is divided into nine provinces, with of coastline on the Atlantic and Indian oceans...
immigrate to practice in Canada. Many Canadian physicians and new medical graduates also go to the U.S. for post-graduate training in medical residencies. As it is a much larger market, new and cutting-edge sub-specialties are more widely available in the U.S. as opposed to Canada. However, statistics published in 2005 by the Canadian Institute for Health Information (CIHI), show that, for the first time since 1969 (the period for which data are available), more physicians returned to Canada than moved abroad.
Drugs
Both Canada and the United States have limited programs to provide prescription drugs to the needy. In the U.S., the introduction of Medicare Part DMedicare Part D
Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries in the United States. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and went into effect on January 1, 2006.- Eligibility and...
has extended partial coverage for pharmaceuticals to Medicare beneficiaries. In Canada all drugs given in hospitals fall under Medicare, but other prescriptions do not. The provinces all have some programs to help the poor and seniors have access to drugs, but while there have been calls to create one, no national program exists. About two thirds of Canadians have private prescription drug coverage, mostly through their employers. In both countries, there is a significant population not fully covered by these programs. A 2005 study found that 20% of Canada's and 40% of America's sicker adults did not fill a prescription because of cost.
Furthermore, the 2010 Commonwealth Fund International Health Policy Survey indicates that 4% of Canadians indicated that they did not visit a doctor because of cost compared with 22% of Americans. Additionally, 21% of Americans have said that they did not fill a prescription for medicine or have skipped doses due to cost. That is compared with 10% of Canadians.
One of the most important differences between the two countries is the much higher cost of drugs in the United States. In the U.S., $728 per capita is spent each year on drugs, while in Canada it is $509. At the same time, consumption is higher in Canada, with about 12 prescriptions being filled per person each year in Canada and 10.6 in the United States. The main difference is that patented drug prices in Canada average between 35% and 45% lower than in the United States, though generic prices are higher. The price differential for brand-name drugs between the two countries has led Americans to purchase upward of $1 billion US in drugs per year from Canadian pharmacies.
There are several reasons for the disparity. The Canadian system takes advantage of centralized buying by the provincial governments that have more market heft and buy in bulk, lowering prices. By contrast, the U.S. has explicit laws that prohibit Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
or Medicaid
Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
from negotiating drug prices. In addition, price negotiations by Canadian health insurers are based on evaluations of the clinical effectiveness of prescription drugs, allowing the relative prices of therapeutically-similar drugs to be considered in context. The Canadian Patented Medicine Prices Review Board also has the authority to set a fair and reasonable price on patented products, either comparing it to similar drugs already on the market, or by taking the average price in seven developed nations. Prices are also lowered through more limited patent protection in Canada. In the U.S., a drug patent may be extended five years to make up for time lost in development. Some generic drug
Generic drug
A generic drug is a drug defined as "a drug product that is comparable to brand/reference listed drug product in dosage form, strength, route of administration, quality and performance characteristics, and intended use." It has also been defined as a term referring to any drug marketed under its...
s are thus available on Canadian shelves sooner.
The pharmaceutical industry is important in both countries, though both are net importers of drugs. Both countries spend about the same amount of their GDP on pharmaceutical research, about 0.1% annually
Technology
The United States spends more on technology than Canada. In a 2004 study on medical imaging in Canada, it was found that Canada had 4.6 MRIMagnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
scanners per million population while the U.S. had 19.5 per million. Canada's 10.3 CT scanners per million also ranked behind the U.S., which had 29.5 per million. The study did not attempt to assess whether the difference in the number of MRI and CT scanners had any effect on the medical outcomes or were a result of overcapacity but did observe that MRI scanners are used more intensively in Canada than either the U.S. or Great Britain. This disparity in the availability of technology, some believe, results in longer wait times. In 1984 wait times of up to 22 months for an MRI
Magnetic resonance imaging
Magnetic resonance imaging , nuclear magnetic resonance imaging , or magnetic resonance tomography is a medical imaging technique used in radiology to visualize detailed internal structures...
were alleged in Saskatchewan. However, according to more recent official statistics (2007), all emergency patients receive MRIs within 24 hours, those classified as urgent receive them in under 3 weeks and the maximum elective wait time is 19 weeks in Regina and 26 weeks in Saskatoon, the province's two largest metropolitan areas.
According to the Health Council of Canada’s 2010 report "Decisions, Decisions: Family doctors as gatekeepers to prescription drugs and diagnostic imaging in Canada", the Canadian federal government invested $3 billion over 5 years (2000-2005) in relation to diagnostic imaging and agreed to invest a further $2 billion to reduce wait times. These investments led to an increase in the number of scanners across Canada as well as the number of exams being performed. The number of CT scanners increased from 198 to 465 and MRI scanners increased from 19 to 266 (more than tenfold) between 1990 and 2009. Similarly, the number of CT exams increased by 58% and MRI exams increased by 100% between 2003 and 2009. In comparison to other OECD countries, including the US, Canada’s rates of MRI and CT exams falls somewhere in the middle. Nevertheless, the Canadian Association of Radiologists claims that as many as 30% of diagnostic imaging scans are inappropriate and contribute no useful information.
Malpractice litigation
The extra cost of malpracticeMalpractice
In law, malpractice is a type of negligence in, which the professional under a duty to act, fails to follow generally accepted professional standards, and that breach of duty is the proximate cause of injury to a plaintiff who suffers harm...
lawsuits is a proportion of health spending in both the U.S. (0.46%) and Canada (0.27%). In Canada the total cost of settlements, legal fees, and insurance comes to $4 per person each year, but in the United States it is $16. Average payouts to American plaintiffs were $265,103, while payouts to Canadian plaintiffs were somewhat higher, averaging $309,417. However, malpractice suits are far more common in the U.S., with 350% more suits filed each year per person. While malpractice costs are significantly higher in the U.S., they make up only a small proportion of total medical spending. The total cost of defending and settling malpractice lawsuits in the U.S. in 2001 was approximately $6.5 billion, or 0.46% of total health spending. Critics say that defensive medicine
Defensive Medicine
Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Fear of litigation has been cited as the driving force behind defensive medicine...
consumes up to 9% of American healthcare expenses. In the same year in Canada, the total burden of malpractice suits was $237 million, or 0.27% of total health spending.
According to American Medical News, eight states saw two or more liability insurers raise rates by at least 30 percent in 2001. In more than 12 states, one or more insurers raised rates by 25 percent or more.
"Across the country, liability insurance for obstetrician-gynecologists is becoming unaffordable or even unavailable," said ACOG President Thomas Purdon, MD.
The situation is particularly worrisome for rural areas, where physicians and care are often already in short supply. "Hospitals, public health clinics, and medical facilities in medically underserved areas begin to lose prenatal and delivery care. The impact on rural women and Medicaid patients is most acute," said Dr. Purdon.
Ancillary expenses
There are a number of ancillary costs that are higher in the U.S. Administrative costs are significantly higher in the U.S.; government mandates on record keeping and the diversity of insurers, plans and administrative layers involved in every transaction result in greater administrative effort. One recent study comparing administrative costs in the two countries found that these costs in the U.S. are roughly double what they are in Canada. Another ancillary cost is marketingMarketing
Marketing is the process used to determine what products or services may be of interest to customers, and the strategy to use in sales, communications and business development. It generates the strategy that underlies sales techniques, business communication, and business developments...
, both by insurance companies and health care providers. These costs are higher in the U.S., contributing to higher overall costs in that nation.
Health care outcomes
In the World Health Organization's rankings of health care system performanceWHO's ranking of health care systems
The World Health Organization ranked the healthcare systems of its 191 member states in its World Health Report 2000. It provided a framework and measurement approach to examine and compare aspects of health systems around the world...
among 191 member nations published in 2000, Canada ranked 30th and the U.S. 37th, while the overall health of Canadians was ranked 35th and Americans 72nd. However, the WHO's methodologies, which attempted to measure how efficiently health systems translate expenditure into health, generated broad debate and criticism.
Researchers caution against inferring health care quality from some health statistics. June O'Neill and Dave O'Neill point out that "...life expectancy and infant mortality are both poor measures of the efficacy of a health care system because they are influenced by many factors that are unrelated to the quality and accessibility of medical care".
In 2007, Gordon H. Guyatt et al. conducted a meta-analysis, or systematic review, of all studies that compared health outcomes for similar conditions in Canada and the U.S., in Open Medicine, an open-access peer-reviewed Canadian medical journal. They concluded, "Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent." Guyatt identified 38 studies addressing conditions including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies with the strongest statistical validity, 5 favoured Canada, 2 favoured the United States, and 3 were equivalent or mixed. Of 28 weaker studies, 9 favoured Canada, 3 favoured the United States, and 16 were equivalent or mixed. Overall, results for mortality favoured Canada with a 5% advantage, but the results were weak and varied. The only consistent pattern was that Canadian patients fared better in kidney failure.
Canadians are, overall, statistically healthier than Americans and show lower rates of many diseases such as various forms of cancer. On the other hand, evidence suggests that with respect to some illnesses (such as breast cancer), those who do get sick have a higher rate of cure in the U.S. than in Canada.
In terms of population health, life expectancy
Life expectancy
Life expectancy is the expected number of years of life remaining at a given age. It is denoted by ex, which means the average number of subsequent years of life for someone now aged x, according to a particular mortality experience...
in 2006 was about two and a half years longer in Canada, with Canadians living to an average of 79.9 years and Americans 77.5 years. Infant and child mortality rates are also higher in the U.S. Some comparisons suggest that the American system underperforms Canada's system as well as those of other industrialized nations with universal coverage. For example, a ranking by the World Health Organization of health care system performance among 191 member nations, published in 2000, ranked Canada 30th and the U.S. 37th, and the overall health of Canada 35th to the American 72nd. The WHO did not merely consider health care outcomes, but also placed heavy emphasis on the health disparities between rich and poor, funding for the health care needs of the poor, and the extent to which a country was reaching the potential health care outcomes they believed were possible for that nation. In an international comparison of 21 more specific quality indicators conducted by the Commonwealth Fund International Working Group on Quality Indicators, the results were more divided. One of the indicators was a tie, and in 3 others, data was unavailable from one country or the other. Canada performed better on 11 indicators; such as survival rates for colorectal cancer, childhood leukemia, and kidney and liver transplants. The U.S. performed better on 6 indicators, including survival rates for breast and cervical cancer, and avoidance of childhood diseases such as pertussis and measles. It should be noted that the 21 indicators were distilled from a starting list of 1000. The authors state that, "It is an opportunistic list, rather than a comprehensive list."
Some of the difference in outcomes may also be related to lifestyle choices. The OECD found that Americans have slightly higher rates of smoking and alcohol consumption than do Canadians as well as significantly higher rates of obesity
Obesity
Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
. A joint US-Canadian study found slightly higher smoking rates among Canadians. Another study found that Americans have higher rates not only of obesity, but also of other health risk factors and chronic conditions, including physical inactivity, diabetes, hypertension, arthritis, and chronic obstructive pulmonary disease.
While a Canadian systematic review
Systematic review
A systematic review is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine...
stated that the differences in the health care systems of Canada and the United States could not alone explain differences in health care outcomes, the study didn't consider that over 44,000 Americans die every year due to not having a single payer system for healthcare in the United States and it didn't consider the millions more that live without proper medical care due to a lack of insurance.
Cancer
Numerous studies have attempted to compare the rates of cancerCancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
incidence and mortality in Canada and the U.S., with varying results. Doctors who study cancer epidemiology warn that the diagnosis of cancer is subjective, and the reported incidence of a cancer will rise if screening is more aggressive, even if the real cancer incidence is the same. Statistics from different sources may not be compatible if they were collected in different ways. The proper interpretation of cancer statistics has been an important issue for many years. Dr. Barry Kramer of the National Institutes of Health
National Institutes of Health
The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...
points to the fact that cancer incidence rose sharply over the past few decades as screening became more common. He attributes the rise to increased detection of benign early stage cancers that pose little risk of metastasizing. Furthermore, though patients who were treated for these benign cancers were at little risk, they often have trouble finding health insurance after the fact.
Cancer survival time increases with later years of diagnosis, because cancer treatment improves, so cancer survival statistics can only be compared for cohorts in the same diagnosis year. For example, as doctors in British Columbia adopted new treatments, survival time for patients with metastatic breast cancer increased from 438 days for those diagnosed in 1991–1992, to 667 days for those diagnosed in 1999–2001.
An assessment by Health Canada
Health Canada
Health Canada is the department of the government of Canada with responsibility for national public health.The current Minister of Health is Leona Aglukkaq, a Conservative Member of Parliament appointed to the position by Prime Minister Stephen Harper.-Branches, regions and agencies:Health Canada...
found that cancer mortality rates are almost identical in the two countries. Another international comparison by the National Cancer Institute of Canada indicated that incidence rates for most, but not all, cancers were higher in the U.S. than in Canada during the period studied (1993–1997). Incidence rates for certain types, such as colorectal and stomach cancer, were actually higher in Canada than in the U.S. In 2004, researchers published a study comparing health outcomes in the Anglo countries. Their analysis indicates that Canada has greater survival rates for both colorectal cancer and childhood leukemia, while the United States has greater survival rates for Non-Hodgkin's lymphoma as well as breast and cervical cancer.
A study based on data from 1978 through 1986 found very similar survival rates in both the United States and in Canada. However, a study based on data from 1993 through 1997 found lower cancer survival rates among Canadians than among Americans.
A few comparative studies have found that cancer survival rates vary more widely among different populations in the U.S. than they do in Canada. Mackillop and colleagues compared cancer survival rates in Ontario and the U.S. They found that cancer survival was more strongly correlated with socio-economic class in the U.S. than in Ontario. Furthermore, they found that the American survival advantage in the four highest quintiles was statistically significant. They strongly suspected that the difference due to prostate cancer was a result of greater detection of asymptomatic cases in the U.S. Their data indicates that neglecting the prostate cancer data reduces the American advantage in the four highest quintiles and gives Canada a statistically significant advantage in the lowest quintile. Similarly, they believe differences in screening mammography may explain part of the American advantage in breast cancer. Exclusion of breast and prostate cancer data results in very similar survival rates for both countries.
Hsing et al. found that prostate cancer mortality incidence rate ratios were lower among U.S. whites than among any of the nationalities included in their study, including Canadians. U.S. blacks in the study had lower rates than any group except for Canadians and U.S. whites. Echoing the concerns of Dr. Kramer and Professor Mackillop, Hsing later wrote that reported prostate cancer incidence depends on screening. Among whites in the U.S., the death rate for prostate cancer remained constant, even though the incidence increased, so the additional reported prostate cancers did not represent an increase in real prostate cancers, said Hsing. Similarly, the death rates from prostate cancer in the U.S. increased during the 1980s and peaked in early 1990. This is at least partially due to "attribution bias" on death certificates, where doctors are more likely to ascribe a death to prostate cancer than to other diseases that affected the patient, because of greater awareness of prostate cancer or other reasons.
Because health status is "considerably affected" by socioeconomic and demographic characteristics, such as level of education and income, "the value of comparisons in isolating the impact of the health care system on outcomes is limited," according to health care analysts. Experts say that the incidence and mortality rates of cancer cannot be combined to calculate survival from cancer. Nevertheless, researchers have used the ratio of mortality to incidence rates as one measure of the effectiveness of health care. Data for both studies was collected from registries that are members of the North American Association of Central Cancer Registries
North American Association of Central Cancer Registries
-North American Association of Central Cancer Registries, Inc. :Established in 1987, NAACCR, Inc. is a collaborative umbrella organization for cancer registries, governmental agencies, professional associations, and private groups in North America interested in enhancing the quality and use of...
, an organization dedicated to developing and promoting uniform data standards for cancer registration in North America.
Racial and ethnic differences
The U.S. and Canada differ substantially in their demographics, and these differences may contribute to differences in health outcomes between the two nations. Although both countries have white majorities, Canada has a proportionately larger immigrant minority population. Furthermore, the relative size of different ethnic and racial groups vary widely in each country. Hispanics and peoples of African descent constitute a much larger proportion of the American population. Non-Hispanic North American aboriginalFirst Nations
First Nations is a term that collectively refers to various Aboriginal peoples in Canada who are neither Inuit nor Métis. There are currently over 630 recognised First Nations governments or bands spread across Canada, roughly half of which are in the provinces of Ontario and British Columbia. The...
peoples constitute a much larger proportion of the Canadian population. Canada also has a proportionally larger South Asian and East Asian population. Also, the proportion of each population that is immigrant is higher in Canada.
A study comparing aboriginal mortality rates in Canada, the U.S. and New Zealand found that aboriginals in all three countries had greater mortality rates and shorter life expectancies than the white majorities. That study also found that aboriginals in Canada had both shorter life expectancies and greater infant mortality rates than aboriginals in the United States and New Zealand. The health outcome differences between aboriginals and whites in Canada was also larger than in the United States.
Though few studies have been published concerning the health of Black Canadians, health disparities between whites and blacks in the U.S. have received intense scrutiny. Blacks in the U.S. have significantly greater rates of cancer incidence and mortality. Drs. Singh and Yu found that neonatal and postnatal mortality rates for American blacks are more than double the non-Hispanic white rate. This difference persisted even after controlling for household income and was greatest in the highest income quintile. A Canadian study also found differences in neonatal mortality between different racial and ethnic groups. Although Canadians of African descent had a greater mortality rate than whites in that study, the rate was somewhat less than double the white rate.
The racially heterogeneous Hispanic population in the U.S. has also been the subject of several studies. Although members of this group are significantly more likely to live in poverty than are non-Hispanic whites, they often have disease rates that are comparable to or better than the non-Hispanic white majority. Hispanics have lower cancer incidence and mortality, lower infant mortality, and lower rates of neural tube defects. Singh and Yu found that infant mortality among Hispanic sub-groups varied with the racial composition of that group. The mostly white Cuban population had a neonatal mortality rate (NMR) nearly identical to that found in non-Hispanic whites and a postnatal mortality rate (PMR) that was somewhat lower. The largely Mestizo
Mestizo
Mestizo is a term traditionally used in Latin America, Philippines and Spain for people of mixed European and Native American heritage or descent...
, Mexican, Central, and South American Hispanic populations had somewhat lower NMR and PMR. Puerto Ricans who often have a mix of white and African ancestry had higher NMR and PMR rates.
Impact on economy
In 2002, automotive companies claimed that the universal health care system in Canada saved labour costs. In 2004, health care cost General MotorsGeneral Motors
General Motors Company , commonly known as GM, formerly incorporated as General Motors Corporation, is an American multinational automotive corporation headquartered in Detroit, Michigan and the world's second-largest automaker in 2010...
$5.8 billion, and increased to $7 billion. The UAW
United Auto Workers
The International Union, United Automobile, Aerospace and Agricultural Implement Workers of America, better known as the United Auto Workers , is a labor union which represents workers in the United States and Puerto Rico, and formerly in Canada. Founded as part of the Congress of Industrial...
also claimed that the resulting escalating health care premiums reduced workers' bargaining powers.
Flexibility
In Canada, increasing demands for health care, due to the aging population, must be met by either increasing taxes or reducing other government programs. In the United States, under the current system, more of the burden for health care will be taken up by the private sector and individuals.Since 1998, Canada's successive multi-billion dollar budget surpluses have allowed a significant injection of new funding to the healthcare system, with the stated goal of reducing waiting times for treatment. However, this may be hampered by the return to deficit spending as of the 2009 Canadian federal budget
2009 Canadian federal budget
The Canadian federal budget for the 2009-2010 fiscal year was presented to the Canadian House of Commons by Finance Minister Jim Flaherty on January 27, 2009...
.
One historical problem with the U.S. system was known as job lock
Job lock
The term job lock is used to describe the inability of an employee to freely leave a job because doing so will result in the loss of employee benefits...
, in which people become tied to their jobs for fear of losing their health insurance. This reduces the flexibility of the labor market. Federal legislation passed since the mid-1980s, particularly COBRA
Consolidated Omnibus Budget Reconciliation Act of 1985
The Consolidated Omnibus Budget Reconciliation Act of 1985 is a law passed by the U.S. Congress on a reconciliation basis and signed by President Reagan that, among other things, mandates an insurance program giving some employees the ability to continue health insurance coverage after leaving...
and HIPAA
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act of 1996 was enacted by the U.S. Congress and signed by President Bill Clinton in 1996. It was originally sponsored by Sen. Edward Kennedy and Sen. Nancy Kassebaum . Title I of HIPAA protects health insurance coverage for workers and their...
, has been aimed at reducing job lock. However, providers of group health insurance in many states are permitted to use experience rating
Experience rating
Experience rating is a method used by insurers to determine pricing of premiums for different groups or individuals based on the group or individual's history of claims...
and it remains legal in the United States for prospective employers to investigate a job candidate's health and past health claims as part of a hiring decision. Someone who has recently been diagnosed with cancer, for example, may face job lock
Job lock
The term job lock is used to describe the inability of an employee to freely leave a job because doing so will result in the loss of employee benefits...
not out of fear of losing their health insurance, but based on prospective employers not wanting to add the cost of treating that illness to their own health insurance pool, for fear of future insurance rate increases. Thus, being diagnosed with an illness can cause someone to be forced to stay in their current job.
Politics of each country
More imaginative solutions in both countries have come from the sub-national level.Canada
In Canada, the right-wing and now defunct Reform PartyReform Party of Canada
The Reform Party of Canada was a Canadian federal political party that existed from 1987 to 2000. It was originally founded as a Western Canada-based protest party, but attempted to expand eastward in the 1990s. It viewed itself as a populist party....
and its successor, the Conservative Party of Canada
Conservative Party of Canada
The Conservative Party of Canada , is a political party in Canada which was formed by the merger of the Canadian Alliance and the Progressive Conservative Party of Canada in 2003. It is positioned on the right of the Canadian political spectrum...
considered increasing the role of the private sector in the Canadian health care system. Public backlash caused these plans to be abandoned, and the current majority Conservative government has re-affirmed its commitment to universal public medicine.
In Canada, it was Alberta
Alberta
Alberta is a province of Canada. It had an estimated population of 3.7 million in 2010 making it the most populous of Canada's three prairie provinces...
under the Conservative government that has experimented most with increasing the role of the private sector in health care. Measures have included the introduction of private clinics that are allowed to bill patients for some of the cost of a procedure.
United States
In the U.S., President Bill ClintonBill Clinton
William Jefferson "Bill" Clinton is an American politician who served as the 42nd President of the United States from 1993 to 2001. Inaugurated at age 46, he was the third-youngest president. He took office at the end of the Cold War, and was the first president of the baby boomer generation...
attempted a significant restructuring of health care
Clinton health care plan
The Clinton health care plan was a 1993 healthcare reform package proposed by the administration of President Bill Clinton and closely associated with the chair of the task force devising the plan, First Lady of the United States Hillary Rodham Clinton....
, but the effort collapsed under public pressure against it. The 2000 U.S. election saw prescription drug
Prescription drug
A prescription medication is a licensed medicine that is regulated by legislation to require a medical prescription before it can be obtained. The term is used to distinguish it from over-the-counter drugs which can be obtained without a prescription...
s become a central issue, although the system did not fundamentally change. In the 2004 U.S. election health care proved to be an important issue to some voters, though not a primary one.
In 2006, Massachusetts
Massachusetts
The Commonwealth of Massachusetts is a state in the New England region of the northeastern United States of America. It is bordered by Rhode Island and Connecticut to the south, New York to the west, and Vermont and New Hampshire to the north; at its east lies the Atlantic Ocean. As of the 2010...
adopted a plan that vastly reduced the number of uninsured making it the state with the lowest percentage of non-insured residents in the union. It requires everyone to buy insurance and subsidizes insurance costs for lower income people on a sliding scale. Some have claimed that the state's program is unaffordable, which the state itself says is "a commonly repeated myth". In 2009, in a minor amendment, the plan did eliminate dental, hospice and skilled nursing care for certain categories of non citizens covering 30,000 people (victims of human trafficking and domestic violence, applicants for asylum and refugees) who do pay taxes.
In July 2009, Connecticut
Connecticut
Connecticut is a state in the New England region of the northeastern United States. It is bordered by Rhode Island to the east, Massachusetts to the north, and the state of New York to the west and the south .Connecticut is named for the Connecticut River, the major U.S. river that approximately...
passed into law a plan called SustiNet
SustiNet
SustiNet is a Connecticut health care plan passed into law in July, 2009. Its goal is to provide affordable health care coverage to 98% of Connecticut residents by 2014.-Provisions of the legislation:...
, with the goal of achieving health-care coverage of 98% of its residents by 2014.
Private care
The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine. Governments attempt to control health care costs by being the sole purchasers and thus they do not allow private patients to bid up prices. Those with non-emergency illnesses such as cancer cannot pay out of pocket for time-sensitive surgeries and must wait their turn on waiting lists. According to the Canadian Supreme Court in its 2005 ruling in Chaoulli v. QuebecChaoulli v. Quebec (Attorney General)
Chaoulli v. Quebec [2005] 1 S.C.R. 791, was a decision by the Supreme Court of Canada where the Court ruled that the Quebec Health Insurance Act and the Hospital Insurance Act prohibiting private medical insurance in the face of long wait times violated the Quebec Charter of Human Rights and...
, waiting list delays "increase the patient’s risk of mortality or the risk that his or her injuries will become irreparable." The ruling found that a Quebec provincial ban on private health insurance was unlawful, because it was contrary to Quebec's own legislative act, the 1975 Charter of Human Rights and Freedoms.
Consumer-driven health care
Congress in the U.S. has enacted laws to promote consumer driven health careConsumer driven health care
Defined narrowly, consumer-driven health care refers to third tier health insurance plans that allow members to use personal health savings accounts , Health Reimbursement Accounts , or similar medical payment products to pay routine health care expenses directly, while a high-deductible health...
. By that they mean Health Savings Accounts (HSAs), which were created by the Medicare bill signed by President Bush on December 8, 2003. HSAs are designed to provide tax incentives for individuals to save for future qualified medical and retiree health expenses; the money placed in such accounts is tax-free. To qualify for these tax-deferred accounts, individuals must carry a High Deductible Health Plan
High Deductible Health Plan
A high-deductible health plan is a health insurance plan with lower premiums and higher deductibles than a traditional health plan. Being covered by an HDHP is also a requirement for having a health savings account. Some HDHP plans also offer additional "wellness" benefits, provided before a...
(HDHP). The higher deductible shifts some of the financial responsibility for health care from insurance providers to the individual consumer. This shift towards a market-based system with greater individual responsibility may increase the differences between the U.S. and Canadian systems. Some economists who have studied various proposals for universal health care are concerned that the main effect of the consumer driven healthcare movement will be to reduce the social redistributive effects of insurance that pools high-risk and low-risk people together. In an attempt to reverse that Democrats have passed legislation that Beginning January 1, 2011, as a result of Health Care Reform, also known as Patient Protection and Affordable Care Act, HSA funds can no longer be used to buy over-the-counter drugs without a doctor's prescription.
See also
- Tommy DouglasTommy DouglasThomas Clement "Tommy" Douglas, was a Scottish-born Baptist minister who became a prominent Canadian social democratic politician...
(1904–1986) "Father" of Canadian Medicare - Health Care and Education Reconciliation Act of 2010Health Care and Education Reconciliation Act of 2010The Health Care and Education Reconciliation Act of 2010 is a law that was enacted by the 111th United States Congress, by means of the reconciliation process, in order to amend the Patient Protection and Affordable Care Act...
- Health care systems (including international comparisons)
- Health care in CanadaHealth care in CanadaHealth care in Canada is delivered through a publicly-funded health care system, which is mostly free at the point of use and has most services provided by private entities. It is guided by the provisions of the Canada Health Act. The government assures the quality of care through federal standards...
- Health care in the United StatesHealth care in the United StatesHealth care in the United States is provided by many separate legal entities. Health care facilities are largely owned and operated by the private sector...
- Patient Protection and Affordable Care ActPatient Protection and Affordable Care ActThe Patient Protection and Affordable Care Act is a United States federal statute signed into law by President Barack Obama on March 23, 2010. The law is the principal health care reform legislation of the 111th United States Congress...
- Universal health careUniversal health careUniversal health care is a term referring to organized health care systems built around the principle of universal coverage for all members of society, combining mechanisms for health financing and service provision.-History:...
External links
- http://www.filmakers.com/index.php?a=filmDetail&filmID=290Borderline Medicine A 1 hour 1990 documentary with Walter CronkiteWalter CronkiteWalter Leland Cronkite, Jr. was an American broadcast journalist, best known as anchorman for the CBS Evening News for 19 years . During the heyday of CBS News in the 1960s and 1970s, he was often cited as "the most trusted man in America" after being so named in an opinion poll...
comparing US and CA systems] - Canadian healthcare, even with queues, bests US, Bloomberg, 18 Sept 2009
- The Agenda:TVO Canadian TV program. Two interviews comparing Canada with US health care (and one comparing Canada with certain European countries)