The Best Solution

...Its recognition led those developing Canadian medicare to make portability a central principle of the system...

...Maternal mortality rates in the United States were double those in Canada in 1988, with seven out of every 100,000 dying in Canada compared to 14 in the U.S...

...No time is spent ensuring that insurance coverage is up to date, that the right hospital is being used for a specific insurance plan, or that the required service is covered by that plan...

...There is, however, evidence that Canada distributes its technology more appropriately and equitably...

...Alice had her surgery booked in the doctor’s office while she was assimilating the news of her diagnosis...

...Or they travel even longer distances at irregular intervals...

...Administration also costs less in Canada because no effort is required to separate the eligible from the ineligible...

...Doctors too enjoy a wide range of choices and freedom from supervision...

...It also means that patients can travel to the services that are seen to be best for their needs...

...In fact, a recent court decision in British Columbia struck down a provision in the fee schedule that penalized new entrants to medicine if they chose to set up their practices in heavily served urban areas...

...Moreover, Canadian hospitals do not have to send out these bills according to the different criteria and forms used by different insurers, do not have to worry about whether they can collect, and do not have to calculate how many “charity” cases they can afford to take on...

...Nor need it be related to the kind of plan available or its conditions...

...In other words, out of every thousand babies born, two more died in infancy in the United States...

...There is, however, evidence to suggest that in the United States “the uninsured receive less trauma-related care and have a higher mortality rate...

...Since the introduction of the Canadian health care system (which they call medicare with a small “m”), the differences in expenditures have steadily and significantly increased...

...While she was living in Ottawa, Pat could still visit the specialist in Toronto who did her regularly required specialty tests, even though it was quite possible to find a new specialist in Ottawa...

...And like many of them, she needed health care while she was away...

...neighbors...

...Hospitals in Canada save on administrative costs not only because they do not have to keep detailed accounts for each patient, but also because they do not have to send each of them, or their private insurer, a bill...

...Although the proportion of public money spent in Canada and the United States is very similar, Canadims get much more for their health dollar and many more Canadians receive care from these public expenditures...

...It may seems obvious to point out that people can fall ill or have an accident anywhere, but this fact has quite important implications for health care coverage...

...Third, although neither country has developed rigorous ways of measuring quality, the establishment of well-funded research centers in Canada with mandates to focus on evaluation and utilization concerns may bode well for the future...

...Or they move for months, even years, to another location...

...health care system BY PAT ARMSTRONAGND HUGHA RMSTRONG WITH CLAUDIA FEGAN How much does it cost...

...Per capita spending on drugs increased by over 100 percent in real terms between 1975 and 1996, rising to $C 362 for every man, woman, and child...

...First, Canadians are much less tied to their employers through health care coverage...

...The existence of a publicly administered health care system in Canada enhances the likelihood that research conducted there and abroad will be translated into improved care...

...While waiting for knee surgery may be inconvenient or even painful, it is unlikely to be life-threatening...

...Drugs now account for more than 14 percent of all health care expenditures, virtually the same amount as that spent on physicians and second only to hospitals in terms of expenditure share...

...Physicians are guaranteed that their fees will be paid at the negotiated rate, and their activities are very seldom scrutinized...

...Yet only a small proportion of such workers are likely to receive health insurance as part of their employment contracts...

...For most there are no premiums to pay for basic care, only taxes...

...There are several reasons why public administration makes for cheaper care...

...It even provides some coverage outside the country...

...A majority of this contingent work is done by women...

...We can assume no such differences exist in Canada, given that everyone is covered for care...

...Women in both countries can be expected to outlive men on average, but Canadian women have the edge...

...Her provincial health card from Ontario gave her immediate entry to the full range of services in Ottawa, her new home during these years...

...Why does Canadian health care cost less...

...It is not surprising then that only 15 percent of Canadians felt their waiting time was unacceptable for this surgery...

...One of the most important areas for cost savings is in administration itself...

...Unlike Medicare and Medicaid in the United States, there are no deductibles or user fees, no limits related to contributions or nature of the plan, no restrictions on which of the insured services can be used, and no means tests...

...Surgery that is deemed medically necessary on an urgent basis is also done quickly...

...Although there is relatively more technology in the US., there is little evidence that all of it is necessary or altered to improve care quality...

...Increasingly, people commute long distances to work...

...Problems 1. Waiting lists...

...With such systems, not only are many individuals left out, especially among the “working poor,” but it is very difficult for any particular plan to control costs...

...All this contrasts sharply with the situation in the United States, where, according to one study, hospitals “must keep more extensive records in order to facilitate billing to the state and federal governments, insurance companies and patients, and in anticipation of malpractice suits...

...From UNIVERSAHLE ALTHC AREW: HATT HE UNITEDS TATES CANL EARNFR OM THE CANADIAENX PERIENCZy EP,A T ARMSTRONaGn d HUGHA RMSTRONGw ith CLAUDIFAE GAN, published by The New Press...

...Second, work restructuring has little impact on health care in Canada...

...As a recent survey of the Canadian system put it, “in virtually all cases, Canadians who need emergency or urgent care receive it in a timely fashion...

...With portable insurance, they have access to medical services in major urban centers where a choice of specialists and a wider range of services are more likely to be found...

...Take babies, for example...

...As one Canadian doctor who tried practicing in the United States explained, “I wasn’t malung any more money [in the United States...

...Canadians therefore have more choice about moving from employer to employer as a result of their portable health care plan...

...To change employers, then, does not mean sacrificing the right to necessary care...

...It happened four times during his brief stay in Idaho...

...hospital after his heart attack scare, he received an itemized bill, detailed down to the sample tube of toothpaste, the aspirin pill, and the laxative he didn’t take...

...In its first 10 month of operation, British Columbia saved an estimated $21 million by generally paying for only the lowest-cost drug in each of three designated “therapeutic categories...

...Illness and injury do not necessarily occur near home, however, and often the need for health care cannot be planned...

...Like many of these people, Pat had moved out of Toronto for a couple of years...

...On such measures, Canada comes out ahead of the United States...

...Canadians do not wait for care that is required immediately...

...A growing number of jobs are part-time, short-term, or simply insecure...

...More importantly, Canadians have a better chance of living free of disability...

...When Larry Haiven was released from a U.S...

...One way is to look at the cost of health care goods and services exchanged as a percentage of all goods and services exchanged - the Gross Domestic Product (GDP...

...On referral from a family physician, Canadian patients can go to any specialist or hospital, as frequently as medically appropriate and for as long as medically necessary...

...What the Canada Health Act calls “public administration” has kept Canadian health care spending under control while providing quality care to the entire population...

...The fee-for-service system under which nine out of 10 Canadian doctors are paid allows them considerable choice about their hours of work and, ultimately, about how much income they will receive...

...In 1995, Canada’s governments spent just under 7 percent of the GDP on health, a figure that is not very different from the 6.6 percent that comes from tax dollars in the United States...

...In the United States, both sexes averaged 60 years free from disability...

...Canada does have a problem with drugs...

...Individual Canadian patients and family physicians choose without outside interference who will be seen, how often, and by whom...

...A much better way to look at the Canadian system is to focus on public costs and the share paid for from the public purse...

...In the case of knee replacement surgery, for example, Canadians waited significantly longer than Americans...

...In contrast, fewer than 30 percent of Americans are covered by government Medicare (13 percent), Medicaid (12 percent), and military (4 percent) care plans combined...

...it is extremely uncommon for patients on surgical waiting lists to diel’ Indeed, there is no evidence that they are more likely to die than their American counterparts...

...Canadians also live longer than their American counterparts...

...For example, this doctor could recall only one occasion during his 11 years of practicing in Saskatchewan when a leg had to be amputated because of complications with diabetes...

...However, none of the research on quality reveals significant differences in the health care in Canada and the United States...

...There are no bills to juggle at the end of the month, no calculations to make about which insurance company to choose or to charge...

...Is health better...

...Comparing hospitals in California and Ontario, this study estimated that “roughly half” the difference in hospital costs could be explained by higher administrative expenditures south of the border...

...Because it is a public health system, people have access to the entire provincial system rather than to a single service organization or to a specific network of providers, as they usually are in managed care...

...The simple answer to the question of why Canadian health care costs less is that so much of it is publicly financed...

...Portability in this sense means moving throughout the provincial system...

...By the late 1970s, Canadian women and men averaged 66 years of disabilityfree life...

...hospital...

...In 1995, Canada spent $2,049 per person, or about 55 percent of what Americans spent per person...

...Although it must be conceded that the Canadian system is more equitable than the US...

...In 1994, six out of every 1,000 babies born in Canada died within the first year...

...What if you get sick away from home...

...Because all Canadians, and most health care services, are included in the public health insurance scheme, this kind of scrutiny to assess eligibility is largely unnecessary...

...No time is taken up with means tests to determine who qualifies for Medicaid, or filling out forms to make sure applicants are old enough for Medicare...

...Emergency rooms are readily available in all urban centers, and all patients urgently requiring care can be admitted without regard to ability to pay, health care plan, or place of residence...

...Usually the monitoring of physicians’ fees simply takes the form of letters sent to a random sample of patients inquiring whether they visited a specific physician on a specific date...

...Patients also have much less paperwork to fill out than do their U.S...

...At the same time, each of them faces unnecessarily high administrative costs...

...There is little restriction on where they locate...

...In 1995, for example, Canadian male babies could be expected to live for 75.3 years on average, while male babies in the United States could be expected to live 72.5 years...

...As we have seen, measuring quality is no simple task, and neither country is very good at it...

...this was the case for eight out of every 1,000 American babies born that year...

...Although Canadian employers do offer some health care benefits, these are extra to the medically necessary services provided under the public plan...

...But health services also have an impact, so it is useful to look at the overall health of a population in assessing the quality of its health care services...

...2. Drugs...

...What about high-tech care - MRls, organ transplants, etc...

...The Canadian hospital had no reason to collect the kind of details he was later to receive from the U.S...

...In consultation with physicians and pharmacists, the province is working to introduce more therapeutic categories to the scheme, but other provinces have not yet introduced similar approaches...

...In Canada, Larry did not receive a bill at all after his first hospital stay with a real heart attack...

...women who in their middle years are much more likely than men to need regular health care...

...alternative, it is on occasion argued that the quality of care is inferior in Canada, especially when it comes to advances related to research and technology...

...My overhead was so much higher...

...More babies die in the United States...

...Indeed, it would have been wasteful to allocate the cost of medications or surgical supplies to individual patients...

...In 1995, Canada spent 10 percent of GDP on health, compared to 14 percent in the United States...

...In this instance, the problem appears to be too much individual choice in the public system, not too little...

...Portability is not restricted to specific geographical areas...

...One reason for this dramatic increase in the amount spent on drugs is that only three provinces have universal drug plans, and only British Columbia uses a reference-based pricing scheme to help control costs...

...This portability is particularly important for those Canadians who live in rural areas or small towns scattered throughout this enormous country...

...This portability of services within the province contrasts sharply with the American private system, which channels health care primarily through employment...

...He returned to Saskatchewan after two years in Idaho, not only because he made less but also because, south of the border, “People did not come until they were very ill,” in order to avoid the expense of care...

...In rural areas, ambulances on the road or in the air can deliver patients quickly to emergency centers...

...The most important measure of care quality must be health...

...They are likely to live to be 81.3 years, compared to 79.2 years for American women...

...The most critical are food, shelter, jobs, and joy...

...Instead, the hospital simply purchases the supplies it needs and in turn provides them to the patients who need them...

...Another way to look at costs is to examine what individuals pay...

...This card is all they have to produce when they enter the hospital, visit the doctor, or use any of the other services available under their provincial program...

...Choosing a new employer is not related to coverage for basic health care services...

...This results in two major differences between the two systems...

...Comparisons between Canada and the United States do reveal differences in waiting times for some kinds of surgery...

...Can Canadians choose their doctors...

...For services covered by public insurance, most Canadians pay nothing...

...There are various ways to answer the question of public health care costs...

...Canadians sign up but once for medicare, receiving one identification card good for the entire range of services...

...Those provinces without universal plans have multi-payer systems that are comparable to those prevailing in the United States...

...With portability under the Canadian public plan, coverage is not linked to either employment or neighborhood, so Canadians have many more choices about services whatever their place of employment or indeed whether or not they are employed...

...In both countries, employment has become more contingent, that is, more precarious, temporary, and insecure...

...In the Canadian system, hospitals and doctors are not alone in enjoying light administrative loads...

...As a mass of research makes clear, health is determined by a range of factors...

...This means that traveling for work need not mean moving away from access to paid care...

...It would have been wasteful to go to the trouble of allocating the cost of insignificant items like toothpaste tubes to individuals patients...

...Public health insurance coverage follows Canadians without a break from service to service, from job to job, and from province to province...

...Before medicare, there were no significant differences in what Canadians and Americans spent on health care services...

...This public money covers every Canadian for a wide range of services...