Medical Care USA and Canada
The universal medical care system in Canada has often been compared with medical care in the US. US politicians rejected the Canadian model when they considered strategies to improve medical care in the US. Arguments against the Canadian system focused on costs and bureaucratic control. Powerful lobbies opposed government monopolies. The spirit of free enterprise and the dislike for bureaucracies, were US "virtues" that Canada lacked. As it turns out, both systems are failing sometimes for the same reasons -- trying to fix end stage diseases is inherently futile --- and sometimes for different reasons. In both countries the cost of delivering medical services escalates.
In 2009, rancorous debate in the US emerged as the Obama administration attempted to "reform healthcare." Competing vested interests promoted irrational fears, common prejudices and paranoid speculation. The first overwhelming problem is the continuing fallacy of "health care". The real concern is providing expensive medical care to the sick and injured. Healthy people look after themselves. The second is that absence of self-responsibility. The third is the absence of recognizing the causes of expensive diseases are built into the infrastructures of the society – bad food, obesity, toxic chemicals in the air and water, alcohol and drug use, accidents, and belligerence.
Since 1967, all citizens in Canada have government provided medical care at little or no cost to each consumer. Funding comes from taxes collected by federal and provincial governments. In my province, BC, you have pay an insurance fee for medical services, but hospital costs are covered by tax revenues. In the early days of the Canadian system, satisfaction was high and many claimed that the Canadian system was the best in the world. Canadian doctors, however, left the country for the US in significant numbers seeking more freedom, better incomes and better funded research opportunities.
Times have changed. The Canadian system has deteriorated slowly but surely. Doctors in primary practice have suffered the most bureaucratic control with the lowest incomes. The trend to close family medicine (primary care) practices continues and more Canadians do not have a doctor to call their own. While specialized medicine and surgery in academic hospitals can provide state of the art medical and surgical procedures, the overall effect on the health of Canadians is minimal. As in the US, endemic diseases in Canada- cancers, diabetes 2, heart attacks, strokes and dementias are on the rise and threaten to bankrupt government coffers. As in the US, absurd slogans such as "Health Care" obscure the real issues and become embedded in endless discussion and debates that lead nowhere.
In Canada, Government control prevails over the cost of medicalcare. An editorial in the National Post ( Friday June 10 2005) stated that Canada is the only free country in the world that forbids citizens from paying for essential medical services with private insurance and the only nation that has defined a particular mode of medicalcare delivery as a core element of national identity. Rationing services is the method of controlling escalating costs. Despite problems, few if any Canadians would want to trade places with the US system.
An editorial in Macleans, a national magazine reviewed the great mistake of 1991 - cutting medical school enrolment: "The bigger lesson here, however, is that any centralized plan for controlling our complex health care system will inevitably flounder on unintended consequences and bureaucratic hubris. Fine-tuning the number of medical school graduates up or down is not a permanent solution. Changing the focus of the system to put patients first, is. As it currently stands, the only effective means Canadians have to influence the quality or quantity of their health care is to lobby politicians. Patients need to be permitted a far larger role in their own medical decision-making. There needs to be a greater emphasis on choice, a bigger role for competing private sector delivery, less restrictive public funding models, greater use of technology and, oh yes, more doctors." ( Fixing a doctor crisis. MacLean’s Magazine March 6, 2008)
Medical care in the United States
A New York Times Editorial in 2007 summarized medical care in the US: "The World Health Organization ranked 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. The Commonwealth Fund compared the United States with other advanced nations, ranking the United States last compared with Australia, Canada, Germany, New Zealand and the United Kingdom. The United States, to its shame, has some 45 million people without medical insurance and many more millions who have poor coverage. The US has the greatest disparity in the quality of care given to richer and poorer citizens. The US has a high infant mortality rate, ranking last among 23 nations. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world. US received low scores in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations." See New York Times Editorial. World’s Best Medical Care? August 12, 2007
Physician commentators such as Glickman-Simon offered a gloomy prognosis. At the American College of Physicians 2006 Annual Session, he stated: "According to the American College of Physicians, the medicalcare system in this country is threatened with an ominous future. Without prompt and significant changes in the way that medicalcare is organized, financed, and taught in this country, the "collapse" of primary care is imminent. What will remain in its place is an increasingly fragmented jumble of poorly coordinated subspecialized services, even higher costs for even lower quality of care, reduced access, rising inefficiency, and more patient dissatisfaction."
Proposals for universal medical insurance have surfaced again in the US campaigns for the 2008 election. Physician and law professor Gregg Bloche summarized an emerging ethic that requires more self-responsibility.
‘The trend is toward an ethic that calls on us to take care of ourselves…this ethic includes high-deductible coverage, financial rewards for regular workouts and weight control, and penalties (such as premium surcharges) for failure to comply with treatment. If the United States is to come close to universal coverage, personal responsibility will need to play a larger role than it did in the mid-20th-century welfare state. The new compact is likely to start with an enhanced sense of individual obligation — to eat sensibly, exercise regularly, avoid smoking, and otherwise care for ourselves. It may include an obligation to buy insurance. Government, in exchange, can offer some protection against the threat of economic and social change that will disrupt people's coverage by destabilizing employment and family relationships. Not only can the state provide subsidies to enable poorer citizens to buy insurance; it can, at low cost, combine people's purchasing power and clear away obstacles to competition, empowering markets to extend coverage to tens of millions who now go without it. Government can also fashion incentives to foster evidence-based practice, health promotion, the elimination of racial disparities in care, and the reduction of medical errors.”
(M. Gregg Bloche, M.D., J.D. Health Care for All? New England Jour Med. Volume 357:1173-1175 September 20, 2007 Number 12 )
Healthy People Do Not Seek Medical Care