Ezra Klein: Canada Middling, America Mediocre

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February 27, 2006

Canada Middling, America Mediocre

Mahablog did a very good job, but I should probably address the New York Times article on the "deterioration" of the Canadian health care system. For those requiring a refreshed course on how CanadaCare operates, head back to my series on the subject. Here's the summary: Canada has a mediocre health care system that's a bit better than ours (Ranked #30 vs. America's #37). It's fully government run, with no allowance for private care of any sort. And what you get is about what you'd expect when a finite government budget is all that powers the system: average care for all, superb for none.

Think of it this way: America has a bipolar health care system that chooses its mood swings based on income. If you're rich, you can get the best knee transplant in the world, and you can do so about three hours from now. If you're poor, you will never, ever get a knee transplant. Ever. Canada, which doesn't allow for that segregation by class, averages the two out: you have to wait a couple months for your operation, and you can't speed it up by flashing some green. So America is much better for some, much worse for many, and about the same for most. Canada eliminates the variance, ending in mediocrity for all.

Canada, however, is not a good health care system. Not compared to France, to Germany, to Japan or to Sweden. Health care is not a finite resource, so outlawing private dollars from any role in the market is a bit silly. So long as you're gonna make money, I can't think of a much more logical place to spend it than medical treatment. Smarter is the French system, which guarantees floor coverage for everyone, subsidizes further coverage for the poor, and let's the rest of the population decide if they want to pay for the upgrade from Corolla to Corvette. Worst of all, of course, is our system. Canada, you should understand, doesn't actually ration. They elongate, they time. They stretch waits and procedures so everyone can get them, but not instantly. That's annoying. America, however, simply withholds treatments from the poor. It's not that they wait, it's that they go without. To my mind, that's criminal.

February 27, 2006 | Permalink

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Comments

Admittedly, sometimes that extended wait could turn into rationing if the patient dies before getting treatment, but that's a pretty damn rare outcome.

I'm still fairly pleased with the Canadian system, but I'd love to move to something more like the French system for exactly the reasons you mention.

Posted by: Mary | Feb 27, 2006 11:01:06 AM

Well, there's a difference between dying before getting treatment and dying because you didn't get treatment. No doubt an 80-year-old might die while waiting for a knee replacement, but obviously lack of treatment for the condition is not what killed the patient.

Also, Ezra doesn't mention the wide swatch of Americans such as myself who do wait for medical treatment. The truth is that most of us already sit around and wait for treatment so that other, previously-scheduled patients can get treatment. Few of us can pay out of pocket for a procedure if we wanted to speed up the process, and even if we could, would be unwilling to, given that we already pay money for health insurance.

Posted by: Constantine | Feb 27, 2006 11:21:31 AM

Add to the consideration that the U. S. health care system increases the cost of health care worldwide. It's especially true in Canada: 500 doctors emigrate from Canada to the United States every year.

Posted by: Dave Schuler | Feb 27, 2006 11:43:17 AM

Canada has no abnormal waiting times for emergency treatment, and some evidence shows Canadians get it quicker. The problems come in elective treatments, like joint replacements.

Posted by: Ezra | Feb 27, 2006 12:47:13 PM

Good evaluation and thinking, Ezra. Canada is not a model that would be accepted in the US if for no other reason that their is no private market alternative.

I think the upgrade to obtain five-star class service is more like Corolla to Infiniti (or Mercedes) however.

Real 'world class', the kind cash-rich corporate executives, prominent politicians, and celebrities get, is prohibitively expensive for all but the few - well beyond what any insurance company will pay, and with providers who don't discount their services as they must if participating in insurance company provider networks. Like buying a 75 foot yacht, if you have to ask how much it costs, you can't afford it.

Those who have the best health insurance in the country still must wait to get great healthcare, and are likely to get an operation performed by a resident-in-training at an academic health center supervised by a Super-Doc faculty member (who also sees private patients in a faculty-practice which demands cash or equivalent for service).

Posted by: JimPortandOR | Feb 27, 2006 1:41:30 PM

The Fraser Institute?!?! Oh, please. Our CATO. Several recent studies have suggested that wait times are in fact falling, particularly in Ontario, though there's a lot of interprovince and rural-urban variation. Saskatchuwan has seen a massive improvement from a very bad starting point (actually that might be from a Fraser study). In BC, on campus, I never have to wait for anything. In New Brunswick, I often waited for weeks and months.

There's also a lot of confusion between private provision of services and private insurance. In Fredericton, my hometown, a little clinic started up where you can pay $10 to have a blood sample taken and sent to the public hospital. It saves the hospital the time and staff to take blood and makes a profit, but the fees aren't enough to impose real inequality of access or provide a market for insurance. The Chaouilli ruling was about insurance, but insurance only makes sense if there are private clinics you can use to pay to jump the queue. Even Jack Layton's NDP is open to the existence of such private clinics but not to private insurance, and I'm pretty sure that many of our hospitals are already private-sector, mainly charitably run out of endowments.

I'm torn. I think Ezra undervalues the importance, the symbolic power, of a society in which we're all in the same boat, face the same risks on this most basic of services. "Choice" in health insurance (not care) is a terribly overrated thing. But most Canadians are very open to nibbling around the edges to make the system run smoother -- but the insurance companies won't want to nibble; they'll want to throw the gate wide open. Also, it's hard to know if the political support will exist to maintain the public system, or to keep doctors from fleeing willy-nilly to the private sector when it serves mainly the poor and sick. (One contentious issue right now in Quebec, in response to Chaouilli, is whether to allow doctors to split their time or to let them stream private or public.) France does it; but the US is hell on its poor. We're a lot closer to the US, though he have managed to keep an inadquate but broad-based welfare system alive without serious attacks on it from the right. I worry what too much privatization will do to our national conception of ourselves.

Posted by: Laura | Feb 27, 2006 4:38:14 PM

It's one thing to guarantee floor coverage for all & even subsidize coverage for the poor. It's another thing to prevent someone from spending their own money for private medical care.

Posted by: Dustin R. Ridgeway | Feb 27, 2006 5:41:33 PM

D R Ridgeway For Canadians, who have 90% of their population within 200 miles of the U.S. border, that distinction is more theoretical than actual. If you can afford the operation, you can afford airfare to wherever outsourcing medical care is an international industry.

Posted by: opit | Feb 27, 2006 9:16:24 PM

Also, as stated upthread, Canada does not prevent anyone from spending out-of-pocket for private medical care. It's only private medical insurance that is prohibited.

Posted by: Thad | Feb 27, 2006 11:44:17 PM

Or, er, was prohibited, I mean...

Posted by: Thad | Feb 27, 2006 11:47:09 PM

Knee transplant? People donate knees?

Posted by: tps12 | Feb 28, 2006 9:28:02 AM

Evian has a lot to say about this over on "Free Canada," a blog devoted purely to Canadian health reform...

http://canada.marketplace.md

~TKM

Posted by: Trapier K. Michael | Feb 28, 2006 10:49:50 AM

In Canada or Britain you wait a bit for elective surgery. In America, apparently, you wait for your insurance company to pull it together. In many respects, it works out the same.

BTW, I remember driving my dad to an appointment at his HMO in (an upmarket area in) Maryland and being astonished at how long we sat there waiting, and then he didn't even know the doctor who saw him. He had an appointment, but he had to wait ages to see some stranger. When I make an appointment with my doctor's office, I wait maybe 15 minutes, tops, and I see my doctor. And I'm not exactly living in Harley Street, here.

Posted by: Avedon | Mar 1, 2006 8:07:48 AM

I've sampled three different healthcare systems now, having had some pretty serious treatment in all three.

With one system I was left 40k out of pocket after treatment, despite having Rolls-Royce health insurance.

With the second, although treatment and medicines are 'free' I never got the treatment I needed because of budget and logistic constraints. The much-vaunted 'choice' was a myth. On the other hand I could call a doctor out at night for an emergency.

I'm now in a third healthcare system, in which I'm covered by a basic insurance premium. Subscribers can't be turned down and can bump up coverage by paying extra premiums. However, the cost of premiums has just doubled; ours is now 200 euro a month (which may seem low to Americans, but is pretty steep here). One can change insurance companies only once a year and there's a penalty for doing so. Formerly the insurance rates were set by government and deducted at source. Now individuals must pay premiums and out of pocket medical expenses from post-tax income, and all bets are off on future premium rises.

For all its faults I prefer system two, the NHS - I've never, ever had to worry whether my treatment depended on the choice of whether to buy food or pay my insurance that month. This is what system one, the US, has now, and which system three, The Netherlands, is moving towards.

The NHS might inadvertently kill me, but at least they won't make me pay for it...

Posted by: Republic of Palau | Mar 1, 2006 9:09:38 AM

I don't like Canada health's system but on the other hand there the medical treatment is on a high level.Maybe some improvements are needed and everything would be just fine.

Posted by: Cara Fletcher | Aug 6, 2007 2:42:08 PM

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