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.
United States
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.
France
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.
United Kingdom
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.
Summary
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.
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Not surprisingly, the opinions about our healthcare system appears to be dependant on our personal experience aceessing, receiving and providing healthcare.I think this may also be the basis for the decisions that our Federal and Provincial government arrives at healthcare policies.
So to add to this- I suggest that our opinions also change as we age and our circumstances change. I use myself as a case in point- I am a retired RN who practiced for 55 years in a variety of provinces and in a variety of roles. While I was in practice I concentrated on the supply side (provision) of the care I was delivering and r lied heavily on a variety of assessment tools to assess the demand side. As a matter of fact one of my positions was to make recommendations to Ontario’s MofH about what tool to use to assess the care needs of LTC residents
If I knew then what I know now!!! I am now old, disabled and require daily healthcare. I am fortunate that much of the care I receive is comprehensive and skillfully provided. There are times however when this is not the case- I am often frustrated by the absence of an emphasis on a feedback loop to the healthcare consumer that is used to determine our Federal and Project Vinci always healthcare policies. I am aware that the BNA Act assigns healthcare to the province’s. It is too bad that the ACT did not make it mandatory that the supply of healthcare services needed to include ongoing input from the demand side and that such input included personal experiences of those for which the healthcare system exists.
In closing and despite what may sound like a criticism, I am proud , both as a nurse and now as a healthcare recipient, to be living in a country where healthcare is a right and not a privilege. Rivie Seaberg
Thank you for this thoughtful and fact based contribution. I hope (and sometimes despair) that our policy makers, and Canadians generally, will carefully evaluate successful systems, such as the French and others, for strategies and tactics that could be applied here. Sadly, I don’t see much evidence of that yet.
Running an office like your French family doctor , solo, in the Canadian system, would be highly inefficient and stressful.
I wonder whether patients are attached or can choose any doctor any day?
Answering the phone and booking appointments during consultations! , would be upsetting for a patient, to say the least. High quality primary care needs team and admin/ tech support to be effective, efficient and timely.
I have only lived in Canada. I am 70 years old and I have only lived in this public health care system where healthcare is rationed where we all have the same right to stand in line, with the right to die while waiting. It is totally supported by all the public healthcare unions.
I got a blood cancer diagnosis(high blood count) in early August of last year. The earliest appointment my family doctor could get with a hematologist/oncologist was on January 30 of this year. He actually laughed and said that they must really be backed up.
I am a Canadian trained RN (45yrs). I have lived and worked in 3 provinces and 2 US states and am a duel citizen. I am still working (LTC now, previously Acute care, ICU, CCU, ER, then Community, Public Health, Prevention, teaching, Programs management and Development, and even Out-Post).
My family are heavy users (surgeries with complications, learning differences, ASD, an MVA, Dysautonomia…)
So- it is my experience that our HCS has deteriorated from lack of funding and complacency – failure to appreciate the value of excellent health care resulting in poor appetite and failure to raise taxes to pay for services considering 80%health care dollars are spent in last 2 years of life. Fortunately, we have/had financial stability in both countries.
In the California, we had access to excellent PPO health care that my husband’s firm paid over $2,500.00 per month -and that was more than 10 years ago and before. I had hip replacements with only 2week wait time! But most people were not so lucky and I saw people on street- still in hospital gowns and still dealing with obvious traumatic health injuries.
Back in Canada, I see best and worst of the Canadian health care system. My personal health care provider/team is part of Toronto’s UHN and I am grateful every day for excellent care including response time, thorough investigations and surgical wait times of less than 2 months for a back and knee operations this year. But, I work in LTC and am troubled by insufficient everything – that makes care for our elderly and most vulnerable unsustainably challenging- and wrong. Loyal staff not only absorb the stress and over-work, but bear witness to and are also traumatized by participating in the delivery of bare-minimum care most of the time. In the past few years dealing with Covid, the staffing crisis has forced us to fill shifts with Agency PSWs, RPNs and RNs who are a blessing and a curse. Many help and care for our residents however, many serve only as place-holders when they actually show up. We are grateful for their help but it is beyond demoralizing for regular staff to know their Agency counterparts are making up to twice as much money and have almost zero accountability.
I could easily retire, but I continue to show up when my health allows – because I can’t turn my back on my colleagues or our residents and their families. I seethe current provincial government as actively undermining our precious public health care system in what seems like his service to corporations and it causes me to dispose over the future of Health Care in Ontario and Canada- which I fear most people will regret giving up because they didn’t want to pay for it. In the mean time, please know, health care workers are humans too- and we all have our breaking point- let’s hope your access point to heal care doesn’t break when you or your loved one needs it most!
Spelling, of course, is not as important as health care but some of us cringe when coming across spelling mistakes in today’s world of artificial intelligence and spelling programs. “Mean time” does not mean “meantime” which is the time between two events. “Duel” and “Dual” have totally different meanings. “Dual citizens” might disagree with themselves, brandish their swords and “duel” with themselves. I once said to a doctor at Toronto General who was supervising some sort of heart test on me, “I get the sense that medicine still has much to learn about the heart.” He leaned close and lowered his voice to respond, “About the whole body.” I was born in a former Austrian town of Romania which subsequently fell into the hands of Russia and is now part of the Ukraine where I received excellent health care in my early years – tonsillectomy, hernia operation, appendix operation, some knee bone problems and eyecare. I learned in those preteen years that medicine often doesn’t have all the answers. They took me to Vienna to a bone specialist who wanted to keep me there for several months because my knee problems stumped him. From 1939 to 1945 on a small farm between Leamington and Kingsville along Lake Erie, I recall seeing a doctor just once, after falling on my behind while loading a 500 lb. barrel of vinegar on a ship in our little harbor. The head of the warehouse on the dock dispatched me to a doctor to check on my coccyx because I had held on to the handles of the dolly as my rear bounced down a ramp into the ship where the barrel might have killed people if I had let go. I have lived and seen doctors in Toronto, New York, Boston and Los Angeles and found good ones and some not so great in each of these cities. For 30 years I suffered from a mysterious gut problem which stumped doctors in Boston, New York, Toronto and Los Angeles. They couldn’t help me because their schools had yet to learn the mystery before they could pass it on to medical students. Thirty years later, a doctor in Western Australia identified a bug which my doctors in Toronto and L.A., figured I had. H. Pylori. Two antibiotics taken concurrently for ten days ended my 30 years of suffering. Medicine, like all sciences, keeps learning and medics often don’t have the answers. So I try to keep myself educated about my health. I smoked for 55 years and may have stopped just in time. When Covid19 came along, I became suspicious and did my own investigation. I refused the vaccination. I predicted that the global ignorance, political larceny and eventual enlightenment will bring mountains of law suits and class action suits which are now getting underway, while media is still trying to cover it all up. I, too, became a dual citizen and very conservative but when it comes to medicine, the Canadian system, at least in Ontario, cannot be compared to the U.S., which I consider unconscionable. A good example was my experience with the PSA test in Toronto in the late 1980s. I had read about it and asked my doctor to prescribe it when it came on the market. At the lab they informed that OHIP wouldn’t cover it. I said I’d pay for it. It turned out to be only $15.00. A year or so later, living in Los Angeles, by now with Medicare coverage, I had the PSA test again. Medicare sends to the patient statements of all procedures they paid for (presumably to keep the doctors and hospitals from cheating) and I noted that Medicare had paid US$85.00 for the same test for which OHIP wouldn’t pay $15. It is one of the many ways the U.S. tax payer gets cheated because some politicians made deals with industry. As it turned out later, the test was somewhat discredited and fell out of favor. I’ll be 96 next September and get monthly eye injections for my macular degeneration. I learned that each injection costs OHIP about $4,000. Without these injections I’d have gone blind by now. Each month, after the injection, I put my right hand over my heart and sing “Oh Canada” with gratitude, sincerity and emotion.