In Michael Moore’s documentary, Sicko, he looked at several foreign health care systems and told the viewer about them. Canada was the first one, and he looked at the features of the Canadian socialized medical system. In Canada, he said, there is free universal health care. While he was, essentially, right, he did not go into the details very well, so there was some misconception passed on by the movie. Some have to do with the impression that it is the same all over Canada, which is not true. Moore also gave the impression that waiting times were short everywhere, and this also is not true. What is true is the essential difference in the attitude of Canadians on health care from that of Americans, and that the Canadian system is better for most people. Canadians do live longer and have a lower infant mortality rate. Most Canadian pay little or nothing out of pocket for health care.
Let us look first at the Canada Health Act (CHA), It mandates that every province and territory have prepaid universal health care for all residents which provides essential health care in hospitals or doctors’ offices and clinics. The cost is shared by the provincial and federal governments. Essential health care is provided everywhere in Canada under a one-payer system and citizens never receive a bill for the covered services. (Health Canada 2008) The system is funded half by the federal government and half by the provincial governments, but provinces can get a deferment of federal taxes for compliance with federal standards. So the poorer provinces get more help from the federal government, keeping the care levels equal across the nation.
The best plan is probably in Quebec, where nobody ever pays for medical treatment of any kind. Prescription costs are low and there is a maximum that any person must pay of around $200 per year. Once that maximum is reached the rest of the prescriptions are free. Not all drugs are available under this system, but a generic equivalent is available for every drug that could be prescribed. In Quebec, citizens are expected to go to their local CLSC, community clinics, for primary health care. They can choose to go to any CLSC and they will be treated. If the patient needs a specialist, a referral must be obtained from the CLSC. These requirements prevent a glut of patients from showing up at the offices of specialists because they think they need that kind of specialist. Everyone who goes to the hospital emergency room is treated. A few hospitals have established a system of 5$ charges if the patient has come to the emergency room when they should have gone to a CLSC. This is simply a reminder that overcrowded emergency rooms are not where one goes unless there is an emergency. One example would be a long-term condition that should have been treated at a clinic, such as an eye infection or respiratory infection. It is not that hospitals do not want to treat these patients, but they are chronically understaffed and nurses are unionized. In addition, care in a hospital incurs a higher cost for the government than care at a clinic. Welfare patients are not charged and they also get dental and eye care. Even people who forget their health cards or do not have one are treated. For a foreigner a bill will be sent at Canadian cost, which ranges from $30 to $1000 or so, depending upon the treatment. The $1000 is generally in-hospital treatment, including a bed. The cost of the entire Quebec system comes out of provincial income taxes. Nobody has turned away without treatment. (Email interview for two Quebec residents 2008, see APPENDIX A).
In Ontario, health care is provided by OHIP (Ontario Health Insurance Program), which goes through the employer. The people who are working pay the premiums, but everyone is still covered. Deductions from the paychecks cover the premiums, which are lower than any in the United States. Ontario has the same kind of network of clinics, which are where people are supposed to go for primary care. OHIP covers dental and eye care also. Nobody has turned away without treatment. (Email interview of one Ontario resident 2008, see APPENDIX A).
The rest of the provinces have similar plans. British Columbia and Alberta follow the Ontario type plan, but unemployed people with adequate income have to pay their premiums of about $50 per month. Most employers cover some dental and some vision. Seniors and welfare recipients are not charges fees. Unemployed low-income people do not pay fees. Clinics are all free. Hospitals are all free and nobody has turned away without treatment. In BC, prescriptions are about $20 each until an annual maximum is reached. Alberta has a Blue Cross supplement that people can buy to cover what does not come under the provincial system for about $55 per month., including a drug, dental and vision plan. (email interview of two Alberta residents who are also former BC residents 2008, see APPENDIX A).
So what Michael Moore says about the cost is essentially correct with small differences. Some provinces cover all prescriptions, which others charge a small fee. Not all provinces cover dental and vision, but emergency treatment involving teeth and eyes are covered, and also any necessary surgery. Seniors and welfare recipients are all covered in every province and territory. Nobody has ever turned away from a hospital without treatment. Coverage is provided under the Canada Health Act.
“Canada’s national health insurance program often referred to as “Medicare”, is designed to ensure that all residents have reasonable access to medically necessary hospital and physician services, on a prepaid basis. Instead of having a single national plan, we have a national program that is composed of 13 interlocking provincial and territorial health insurance plans, all of which share certain common features and basic standards of coverage. Framed by the Canada Health Act, the principles governing our health care system are symbols of the underlying Canadian values of equity and solidarity.” (Health Canada 2008)
Deber (2003) wrote that the Canadian Health Care services recognize that health care for profit does not follow the usual economic rules of supply and demand, and predicting demand is almost impossible. She says that systems like the Canadian health care system recognize this fact and provide for all citizens the basic necessary health care. She lists the requirements for the provinces to get their federal subsidies for health care. Public Administration must be “administered and operated on a non-profit, basis by a public authority appointed or designated by the government of the province and its activities subject to audit.” Health care is delivered by private practices. Only the payments for care are administered by the government or its designated and monitored substitute. Coverage must include all insured health services provided by hospitals, medical practitioners, or dentists, and where the law of the province so permits, similar or additional services rendered by other health care practitioners.” Universality must be guaranteed, that is, “one hundred percent of the insured persons of the province to the insured health services provided for by the plan on uniform terms and conditions. “Provisions must be in place to cover insured people when they move between provinces, and to ensure orderly (and uniform) provisions as to when coverage is deemed to have switched.” Out-of-province costs are covered at the rate of the covering province and the persons receiving the care pay the difference. (This is why Canadians are afraid to enter the US without specific travel insurance.) “Provincial plans must “provide for insured health services on uniform terms and conditions and on a basis that does not impede or preclude, either directly or indirectly, whether by charges made to insured persons or otherwise, reasonable access to those services by insured persons” (Government of Canada, 1984).
“Canada has universal coverage, excellent health outcomes, minimal paperwork, and high public satisfaction, although coverage or reimbursement decisions do tend to become political. One key advantage is the avoidance of risk selection; no one is uninsurable. “ (Debor 2003) In this way the pool for risk is spread across all members. It must be mandatory or it will not work. If contributions to the universal system were voluntary, the government would end up with all the high-risk payers and none of the low-risk healthy payers. When profit enters the picture, the cost of care is high and payouts by insurance are low. This is the main reason that Canada refused to allow health care into the Free Trade Agreement. A two-tier system would be doomed to fail, and Canadians would lose their universal coverage.
Health care is always rationed. In the US it is rationed by cost. Those who can pay get the best care. In Canada, it is rationed by need: those who need available facilities more get them. This does cause some waiting lists for things like surgeries and tests. However, these waiting lists are not usually that long, especially in the more populated areas. In any case, if the patient’s need changes, they can be moved to the top immediately. Canadians favor a mixture of socialist caring and free-market practicality. Foreign students pay an extra fee from $50 to $150 per term for insurance, because they will be treated in any case, so the schools collect upfront. There is a high tax on alcohol and tobacco often called a “sin tax”. What is emphasized in many studies is that, while Canadian life spans are longer than the US, their spending on health care is about half per capita than in the US. Himmelstein and Woolhandler (2003) say that “At least 41 million people residing in the United States have no health insurance, and millions more have inadequate coverage.” They favor a single-payer national health system. (See their list of reasons in APPENDIX B).
One study consulted showed the results of interviews with physicians who have practiced in both the US and Canada. It showed that more physicians left Canada because of lower pay, and more voiced dissatisfaction with the system in Canada. (Haynes, Haynes and Dykstra 1993) However, at the time of this survey, the system was still experiencing considerable change. In addition, the odds of being sued for malpractice in the USA are five times higher than in Canada. In addition, in Canada, doctors have nothing to do with the costs or payments. Decisions are made based on need.
One American who now lives in Quebec was interviewed by Trudy Lieberman (1990) of Consumer Reports after the death of her husband from Malignant Melanoma. A whole article was written for the September 1990 issue about this family’s loss, because they could not get treatment before the cancer spread. According to Moore, this has since become quite common. Mrs. A said that the treatment her husband received in Canada would have cost at least 2.5 million dollars in the US, and he would have died in pain because as soon as Medicaid would have kicked in after the family was stripped of everything they owned, the doctors would have done everything to keep the money coming. She said that her husband had finally qualified for insurance after the diagnosis and she bought a very expensive policy that cost more than their income to cover the one operation he had. Still, they wound up in debt for $30,000. They sold everything and moved to Canada, as her husband was a Canadian citizen. One of their children was hurt before their coverage became valid (3 months) and treatment was covered anyway.
Health Care Canada provides links to provincial health card information, including benefits and costs on their pages. The different plans have different coverage and finance the provincial portion differently. However, everyone has coverage for necessary health care. There are waiting lines for some operations, tests, and procedures. However, anyone in dire need is treated and patients are not shipped out to shelters without treatment. Do people sometimes wait for months for something like a coronary bypass? Yes. However, this treatment is often not covered in the US by HMOs and none of the uninsured millions can get it. US hospitals can refuse treatment just because the patient cannot pay. That will not happen in Canada.
One of the major reasons the Canadian system has been investigated is the lower costs of administration. “(It now takes more people to administer Blue Cross in Massachusetts than to administer the entire Canadian health insurance system.)” (Judis, John B, 1993) “Despite not covering nearly one of every six Americans, we spend far more on health care per capita (including the uninsured), and as a fraction of gross domestic product, than do citizens of any other country.6” (DeGrazia, David, 2008) “Comparing the United States with Canada, its neighbor, the United States spent 12 percent of GNP on health care as compared with 8.6 percent for Canada.” (Jones, 1992) The difference has increased since this article was written, as US administration costs have soared and Canada’s have stayed essentially the same.
Life Expectancy differences were not mentioned in Moore’s documentary, but there is a rising difference, with Canadians the clear winners. White American life expectancy was the same as, or better than, that of all Canadians for most of the period from 1850 to 1950 (Haines and Steckel 2000, 696–7). Stephen J. Kunitz and Irena Pesis-Katz (2005) suggest that the “Canadian system of comprehensive care, free of charge at the point of service, and with a greater emphasis than in the United States on primary care, maybe generally more effective than the American system.”
An interesting part of Moore’s documentary was the suggestion that an American could get health care by marrying a Canadian. That is true, but each Canadian can only do that once, using their one-lifetime sponsorship right. However, living common law can qualify one for Canadian permanent residency, and that carries coverage with it. “Landed immigrants” as they are called, qualify for every right in Canada, except the vote. So that little bit is true, but with some provisions. One cannot simply find an eligible Canadian and marry to get in. It still requires an immigration application.
On the whole, Michael Moore’s description of the Canadian system was correct, but he left out the fact that it is not one plan, but 13 plans under federal requirements. All plans must provide at least the mandated minimum set by the Canada Health Act. Some provinces offer more. Health care in Canada depends upon the needs of the patient, not their ability to pay. Higher taxes and mandated membership make this possible. The one-payer system saves a great deal on administration costs and nobody has ever turned away from a hospital. People choose their doctors and the doctors decide what is needed, not based upon cost. What the person on the golf course with Michael said was true. The system is based upon the very Canadian outlook that we have to take care of our people. (What a socialist idea!) All Canadians and legal residents are covered. No bills are sent and no person is turned away when they need medical care. Even prescriptions are affordable. So Michael Moore was not exaggerating when he talked about the Canadian Health Care system.
APPENDIX A
Short email Survey of some Canadian Residents:
1. What is your province of residence?
- Respondent 1: Quebec
- Respondent 2: Ontario
- Respondent 3: Alberta
2. Have you lived in any other province? If yes, please say which and answer for the second province of residence also.
- No
- No
- Yes, BC
3. How does health care work in your province?
- Everyone is covered. You need a referral to a specialist. Prescriptions are cheap and nobody pays more than $200 per year. Welfare people and seniors get free prescriptions. Dental care and vision are limited to hospital treatments, except for welfare recipients and seniors who are covered.
- Everyone is covered. OHIP is deducted from paychecks. Drugs are cheap and seniors and poor people get them free. Dental and vision are covered in-hospital care and many employers cover other care.
- Everyone is covered. There is a fee for those who can afford it. Seniors and welfare beneficiaries are covered. Dental and vision are limited. In Alberta, there is supplemental care you can buy for maybe $50 per month for what does not come under Alberta health care. Alberta Health includes ambulance payment once a year, once-year eye exams, and supplement for glasses, but no dental. BC is similar but people who do not work and are not poor pay their health plan at about $57 per month. Clinics and hospitals are free with a health card. No hospital refuses to treat anyone.
4. How is health care paid for?
- It comes out of income tax.
- It is paid by employee deductions by employed people.
- Most are paid by the employer, but individuals are also billed if the employer does not pay.
5. Who pays the doctor?
- The province
- Ontario government
- Alberta Health pays in Alberta and BC pays in BC.
6. Where can you get health care?
- Anywhere is it provided?
- Clinics, hospitals, and private practices
- Clinics, specialists with referrals, and hospitals.
7. What is covered?
- Everything but glasses and dental, but poor people gat vision and dental. Prescriptions are cheap.
- Whatever the doctor says you need, including a prescription for most people. A small fee is charged for prescriptions if the employer has no drug coverage.
- All the necessary things, except vision care and dentistry, and seniors get eye care. Prescriptions are very low priced and free for needy people.
8. Do hospitals treat all people who come into emergency rooms.
- Of course
- Yes, always
- Certainly
APPENDIX B
TABLE 1-Key Features of Single-Payer National Health Insurance
Universal, comprehensive coverage: Only such coverage ensures access, avoids a “2-class” system, and minimizes the administrative expense
No out-of-pocket payments: Copayments and deductibles are barriers to access, administratively unwieldy, and unnecessary for cost containment
A single insurance plan in each region, administered by a public or quasi-public agency: A fragmentary payment system that entrusts private firms with administration ensures the waste of billions of dollars on useless paper-pushing and profits. Private insurance duplicating public coverage fosters 2-class care and drives up costs: such duplication should be prohibited
Global operating budgets for hospitals, nursing homes, HMOs, and other providers, with the separate allocation of capital funds: Billing on a per-patient basis, creates unnecessary administrative complexity and expense. Allowing diversion of operating funds for capital investments or profits undermines health planning and intensifies incentives for unnecessary care (under fee for service) or undertreatment (in HMOs)
Free choice of providers: Patients should be free to seek care from any licensed health care provider, without financial incentives or penalties
Public accountability, not corporate dictates: The public has an absolute right to democratically set overall health policies and priorities, but medical decisions must be made by patients and providers rather than dictated from afar. Market mechanisms principally empower employers and insurance bureaucrats pursuing narrow financial interests
Ban on for-profit health care providers: Profit-seeking inevitably distorts care and diverts resources from patients to investors
Protection of the rights of health care and insurance workers: A single-payer reform would eliminate the jobs of hundreds of thousands of people who currently perform billing, advertising., eligibility determination, and other superfluous tasks. These workers must be guaranteed retraining and placement in meaningful jobs ( Himmelstein and Woolhandler, 2003).
References
- Deber, PhD, Raisa Berlin, 2003, American Journal of Public Health, 2003. Vol 93. No. 1
- DeGrazia, David, 2008, “Single Payer Meets Managed Competition: The Case for Public Funding and Private Delivery,” Hastings Center Report 38, no. 1 (2008): 23-33.
- Government of Canada. Canada Health Act. Hill C-3. Statutes of Canada. 32-33 Elizabeth 11 (RSC 1985. e 6: HSC 1989. cC-6). 1984.
- Hayes, Gregory J.,MD MPH, Hayes, PhD, Steven C. and Dykstra, Thane BA, American Journal of Public Health 1993, Vol. 83, No. 11, 1544-47
- Haines, M.R., and R.H. Steckel, eds. 2000. A Population History of North America. Cambridge: Cambridge University Press.
- Health Canada, 2008.
- Jones. Mary Gardiner, 1992, Consumer Access to Health Care: Basic Right 21st Century Challenge, The Journal of Consumer Affairs, Vol. 26, No. 2, 1992, p221
- Judis, John B. 1993, The Jobless Recovery, The New Republic, 1993
- KUNITZ, STEPHEN J. with IRENA PESIS-KATZ, 2005, Mortality of White Americans, African Americans, and Canadians: The Causes and Consequences for Health of Welfare State Institutions and Policies, The Milbank Quarterly, Vol. 83, No. 1, 2005 (pp. 5–39), Blackwell Publishing
- Lieberman, Trudy, 1990, The Crisis in Health Insurance, Consumer Reports, 1990