Is Canada in a health-care crisis? If you’ve kept up with the news, obviously, yes. Are the causes for this similar to other places in the Western world? Again, yes – aging populations and retiring clinicians are putting pressure on many Western systems.
So, does our salvation lie in privatizing health care, like the United Kingdom or the United States? Hmmm.
During my professional career, my family and I lived in four different countries (including Canada). Each country has significant differences in the delivery of care and how it is paid for.
Since its broader inception in 1968, Canada’s health-care system has been providing clinical care for nearly all health conditions for all residents. It’s been shaped by the ethos that no one in need is denied care. This was the system, warts and all, that I grew up with. My family and I then left for a series of multi-year foreign assignments. This essay is about those first-hand experiences.
The U.S. health-care system is all about business. Big Business. Health care is delivered in all the familiar ways through hospitals and family doctors. About 50 per cent is funded by federal, state and local governments.[JR1] However, to pay for this care you either have to be privately insured, be wealthy or on government assistance. Bankruptcies due to medical bills are common as is access to credit, limiting upward mobility. Income tax is much lower in the U.S. but the cost of health-care insurance averages (for a 60-year-old) between $800 and $1,200 per person per month. Unless you can demonstrate an ability to pay, you may be denied any form of care and turned away.
And health care there is expensive. According to the CBC, some U.S. COVID patients faced bills of $50,000 or more for their hospitalization.
Not only is this big business but it is tremendously complex, further magnifying costs. Our family physician was in practice by himself. He had one or two nurses, a receptionist and six administrators who only dealt with insurance matters. For hospitals, the system becomes even more complex. Say you have insurance and your doctor is recommending a surgery that requires a hospital stay. Not so fast. Your insurance company gets involved and may, or may not, agree that the operation is necessary. You read that correctly. The insurance company determines whether you can get your surgery. Assuming you get over that hurdle, your coverage will also dictate which hospitals and doctor you see. Every time you need substantive care, the provider bills the insurance company down to the last pill and bandage. Then the fun starts! Inevitably, the insurance company will find fault. The hospital doesn’t get fully reimbursed and the patient is then expected to pick up the balance. At this point, there are tons of questions and negotiations. Picture six months of “please hold … your call is important to us.” It’s all about maximizing revenue, adding a tremendous amount of cost to the provision of care.
If you are especially wealthy or have top-tier insurance, health care is gold-plated
But if you are especially wealthy or have top-tier insurance, health care is gold-plated. Their physicians are among the best of the best, equipment and testing capabilities are amazing. There are truly world-class institutions, like the Mayo in Rochester, Minn., with its marble walls and grand pianos in every lobby that patients frequently play. A visiting physician from New Zealand told me that Mayo may be the Disneyland of medicine but he could not wait to get back home – the fact that it only serves the very privileged did not sit well with him.
On the surface, the health-care system is much closer to Canada’s and also is largely government funded. However, while we lived there our first exposure to family health care revealed stark differences. Our physician ran an open clinic for the first hour of the day; Saturday morning appointments were available. The doctor answered his own phone and kept his own calendar. There was no nurse or staff of any kind. The desk in his examination room/office had a cash drawer for the small copay fee. Yes, he made change! The family doctor would also make house calls as needs arose that could be arranged on the same day.
The French system was highly responsive. A member of our family had a cancer diagnosis on Dec 24. The following week, despite it being between Christmas and New Year’s Day, a plan of attack was mapped out, surgeon visits were held 10 days later (two doctors for a second opinion!) and, by the time three weeks had elapsed, the surgery was complete. Chemo and radiation treatment followed a similarly expeditious timeline. Everything seemed designed to be timely and simple.
There was a small copay for prescriptions. Like here, dentistry is excluded.
Would this work in Canada? Maybe. French doctors have their training paid for so they didn’t graduate with the great debt they have here. That’s a considerable incentive.
In summary, it was a responsive quality system for primary care and more.
Health care is provided in a two-tier system. Taxes pay for all aspects of care at a basic level. However, there are significant backlogs and some doctors (especially specialists) will not work for the public system while others work in both. Anyone who can afford it can get private insurance, allowing some to jump the queue. The difference in wait time can be in excess of a year. Prescriptions are covered with a small copay. Again, dental care is not covered.
However, we became concerned about the quality of care while we were there. Hospitals are spread far apart in terms of travel time. Not all hospitals operate an emergency department, which cuts into that golden hour critically injured patients need before mortality significantly increases. The hospitals we visited (near and in London) were dark, dreary and cluttered. Patient rooms were tired and dirty. Many of the nurses were agency staff, didn’t work the same wards day to day and understandably took little interest in somewhere they were only temporarily placed. In one exceptional situation, my wife required surgery that took longer than expected. By the time she was out of the operating room, the orderlies had all gone home as had almost all the nursing staff in recovery. It came down to me and a nurse off the ward to retrieve her and look after the immediate post-surgical care.
However, in our experience the system excelled in home care, at least in western Scotland. A dying relative was well supported in his last weeks. A palliative nurse made daily visits, personal support workers came up to four times a day and there was a 24-hour-a-day call out literally at the push of a button. All were attentive to the caregiver’s ability to cope. The home care avoided the need for a long-term care facility.
Ranking health-care systems is an exercise that can easily trip you up. Different factors, measurement methods, etc., can yield wildly different results. However, it is clear our system is not great in terms of outcomes, wait times or the cost of providing services and is deteriorating. The U.S. is considerably worse in cost and suffers from the societal and economic effects of not providing universal access.
In my experience, the French system is the best performing one for patient care. It works well, is operationally lean and is accessible to all.
I, like everyone else, don’t have all the answers on how to fix our health care. However, there are things that can and should be done. There are also some dangerous curves ahead that need to be avoided if we are to retain the core values of our health-care system. I’ll share other personal perspectives in Part 2 of this essay.