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The current health care debate in the United States has had the effect of stoking our own debate on the Canadian health care system—and some misunderstandings about proposals for health reform in the United States have had the effect of perpetuating several myths regarding the Canadian health care system.
The ongoing debate south of the border should give us pause as a profession, as it is leading to a distorted reflection of our health system and, ultimately, ourselves. Such misunderstandings no doubt affect the way Canadians view their health care system and might in turn create national negativity toward a system that is, in my view, working.
My perspective is that of an American-trained physician who came to Canada to complete a family medicine residency. I trained in a public hospital in North Carolina that served many of that state’s uninsured. The uninsured of North Carolina are the working poor, as in most of the United States. Indeed, my patients’ stories were tales of woe—inaccessible health care, end-stage presentations of preventable disease, and growing insurmountable debt.
For the first time in more than a decade, health care has become a potluck, church, and dinner table conversation in my home town. However, as I piled on another spoonful of baked beans at a wedding attended last July, the discussions I overheard were not belabouring the details of the contentious Health Care Reform Act; rather, they were corroborating the media’s representation of the “Canadian health care system”—refusal to treat based on advanced age, devastating wait times for emergent surgeries, or inaccessibility to state-of-the-art diagnostic testing. Being American and Canadian trained, I have found myself addressing many of the myths surrounding this contentious debate on both sides of the border at a number of social gatherings, as well as in the clinic.
In opposition to the Health Care Reform Act, Republican Senator Judd Gregg said that a government insurance program being considered in the United States “is a slippery slope to a single-payer system like Canada or England.”1 Those who oppose this bill are quick to compare its contents to a single-payer system. In reality, however, the bill adds to the hodgepodge, multipayer American system, hoping to insure the uninsured and making health insurance more affordable. In short, it means to expand health care coverage to the approximately 40 million uninsured Americans2 by lowering the cost of health care and making the system more efficient. To that end, this includes a new government-run insurance plan to compete with private companies, a requirement that all Americans have health insurance, a prohibition on denying coverage because of pre-existing conditions and, to pay for it all, a surtax on households with an income above $350 000.3
As one of my medical school professors stated, the American health care system is not a system. I compare it with a nearby household in my hometown neighbourhood—with the passing of every year, an addition was hurriedly added with little attention to function or appearance. As time passed, an RV became amalgamated with the 4 multicoloured attachments in addition to a few tents and a garage. This house was quite a departure from my very traditional home life, but it was not ideal for a growing, busy family. Obama’s plan adds a brand-new RV to the house to replace the 40 million tents in the yard.
Even more stirring in the health care debate are certain statements made by elected officials. For example, Republican Senator Mitch McConnell cited the case of a friend who had “just lost a friend of his in Canada because the government decided he was too old for a certain kind of procedure.”4
In the South, many of our stories begin with “I know a friend who has a friend,” which inherently gives only suspect merit to Senator McConnell’s comments. However, this statement did create a stir among the church ladies with whom I shared a pew for most of my childhood and adolescence. One technology-savvy octogenarian wrote me an e-mail to confirm Senator McConnell’s statement—would I as a physician be forced by the government to refuse care to a patient on the basis of age in Canada?
Physicians in Canada have far less third-party interference than physicians in the United States do. For multiple reasons, including greater physician autonomy and less fear of litigation, physicians in Canada are better able to provide evidence-based medicine, the cornerstone of medical practice.
Insurance company preapproval for certain procedures and diagnostic testing consumes a tremendous amount of physicians’ time and energy in the United States. My most vivid memory of this vetting process is of being in medical school and listening to an intensive care unit physician arguing with an insurance company agent for not allowing an emergent, life-saving organ transplant to take place. The US-based insurance company refused to cover the costs because the patient had not had a routine dental visit in the past year. The agent on the phone had no formal medical training. After several hours via multiple chains of command, the physician finally spoke with another physician who granted approval for the transplant pending a dentist’s examination of the patient in the intensive care unit.
It is estimated that one-quarter of health care costs in the multipayer system are administrative, creating a tremendous burden on both physicians and patients in the United States.
According to the American Academy of Family Physicians, in the past 10 years 90% of medical school graduates in the United States have opted to enter into subspecialties. Only 10% have chosen primary care.5 These figures are in comparison with the nearly 40% of medical graduates in Canada who were matched to family medicine in 2009 by the Canadian Resident Matching Service.6 It is no surprise, therefore, that Americans see 40% more doctors, most likely owing to increased specialist referrals and self-referrals.7
My experience as a medical student in North Carolina attests to such figures. Even at a public medical school with a very strong family medicine department, there was tremendous pressure to choose subspecialty residency programs over primary care. In my class of 160 students, 14 went into family medicine, and we all heard comments from our staff physicians such as “what a waste of a good doctor” and “you will be bored in family medicine.”
The shortage of primary care physicians in the United States means many patients do not have primary care providers organizing multiple medical diagnoses or taking responsibility for preventive care. It is like a football team not having a quarterback. President Obama’s Health Care Reform Act seeks to give more than 40 million Americans better access to health care; however, should it be enacted, it will likely be very difficult for those Americans to actually access health care because of the lack of primary care physicians.
This prediction regarding limited access to health care owing to lack of primary care physicians is based on the events following the passing of a 2006 health care reform law in Massachusetts that required all medical residents to have health insurance. The influx of more than a quarter of a million newly insured residents led to overcrowded waiting rooms and overworked primary care physicians who were already in short supply in Massachusetts.8,9
Health care reform is a contentious and divisive issue in my home town this year. Even at neighbourhood potlucks, it replaces talk of traditionally divisive issues such as war, abortion, and gay marriage. Unfortunately, rather than focusing on the need to change the US system, the debate vilifies the Canadian single-payer structure and offers a distorted view of health care across the border. As Canadian family physicians, we should use the attention garnered from the American debate as an opportunity to increase public awareness of successful elements of our system and to highlight failing areas, rather than allowing a wide net of negativity to be cast over the entire Canadian health care system.