Where Does That Leave Us?

May 25, 2007
Surgical Rounds®, March 2006, Volume 0, Issue 0

Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

For many years we have all heard about the wonders of the Can?adian health care system. It's reported to provide universal access to care, an almost paperless payer system, and superb quality. Somehow the long waits for such routine procedures as herniorrhaphy, coronary revascularization, and hip replacement, among many others, have been glossed over. The system is said to be so perfect that many have suggested that the United States should adopt it immediately.

Don't get me wrong. We can learn many lessons from our northern neighbors. The documentation for services provided is much more predictable and the administrative processes are far simpler. Canadian surgeons and their nurses do not have to spend hours on the phone each day getting preauthorization for procedures patients need.

On the other hand, those of us who have friends who practice in Canada have heard a slightly different version. While billing and collecting are fairly easy, rates of reimbursement are very low. Canadian surgeons work much harder and perform many more procedures than we Americans, yet they earn far lower annual incomes.

Now a new problem has surfaced, not from the physicians, but from the plan administrators and politicians. The costs of health care are rising so rapidly that the system cannot be sustained indefinitely. To solve the financial crunch, consideration is now being given to privatizing some components of Canadian Medicare. This shouldn't be shocking. There already are physicians and clinics that have learned ways around the prohibition against private care. The government obviously realizes this, but has turned a blind eye.

Dr. Brian Day, a well-known Van?couver orthopedic surgeon, is a leading spokesman for the concept of a hy?bridized public-private system like the extant systems in most nations in Europe. A sports medicine guru, he compares Canada's health care system to a professional athletic team. He is quoted as saying, "Imagine you?are ranked last in a 30-team league and yet your payroll is one of the third or fourth highest. Well, you know what would happen."* This analogy is quite relevant. The Canadian health care system is ranked 30th worldwide by the World Health Organization (WHO), yet is among the top four nations in per capita spending. For point of reference, our health care system is ranked 37th.

The Globe and Mail,

It seems clear that Canada has recognized the financial concerns. In an article in syndicated columnist Gary Mason reported that "No one is looking here and saying: ?Boy, that is the system to copy. That is the system that is really working.' Are you kidding me? Other governments look at what it's costing to prop up the system and recoil in horror."*

While it is clear that something drastic needs to be done, the exact solution for Canada is far less obvious. There is a real fear that any privatization will result (heaven forbid) in a health care system like ours, and that is a pariah to the Canadians. In addition, the Canadian system has been accepted by the public for such a long time that any significant change will be politically risky. Un?fortunately, it will likely take a crisis for Canada to hybridize its care delivery system.

There are many examples of effective public-private health care blends. The French system, voted best by the WHO, has a universal component with private options for immediate care and more at?tractive accommodations. The British have annealed their system by adding a private sector onto the longstanding National Health Service. There are other well-tested models for the Canadians to choose from. They just need to decide and act before it's too late.

Where does that leave us

in the United States? We have a very well developed but expensive private system and a public or charity system that is hit or miss at the very best. More than 40 million Americans have no health insurance, and that is clearly not acceptable. Our nation needs to provide universal access to health care. So while Canada is seeking to privatize or hybridize their Medicare, we need to develop a reliable public health care system, or better yet, provide affordable insurance for the medically underserved. The only thing that we have in common is the need for change.


*Mason G. The fatal sickness of a broken system. The Globe and Mail. November 12, 2005:A3.