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The Editor, Current Oncology December 2009
The Canadian health care system is at times a source of pride and envy. This government-funded universal health care system covers core physician and hospital services with no copayments and other patient charges 1. Whenever there is a comparison with the United States, the Canadian system seems to come out ahead in most health care indicators. Canadians now live 2.5 years longer than Americans do 2.
Most people who have actually used the system know that there are major deficiencies in the way health care is provided. There are major delays in the system, and this leads to major problems, as highlighted in a 2005 Supreme Court of Canada judgment 3. There have been repeated pushes to privatize at least part of the system in the name of improving efficiency and allowing greater access to patients.
Working as a medical oncologist in Newfoundland, I have seen the strengths and weaknesses of the Canadian system up close. My initial training was in the hospitals of the United States, which in some ways are similar to those of the Canadian system, except that the U.S. system is driven to a large extent by commercial interests. For the past year or so I have been working in Pakistan. Its health care system—if you can call it one—might as well be from another planet. Having seen health care delivery from different angles, I have come to appreciate some of the critical points of the system in place in Canada.
Health care is a costly business. Most physicians working in Canada have vague ideas about the cost of the treatments they are actually prescribing. They are seldom faced with the real costs. Patients have an even poorer understanding of health care costs. However, tertiary care is expensive in any part of the world, and Canada is no exception.
In major parts of the world, including Pakistan, the health safety net provided by government institutions is almost nonexistent. Individuals have to pay for most expenses, including hospitalization and inpatient and outpatient drug costs. Laboratory and diagnostic tests are also included on patient’s tab. Physicians working in a health care system like Pakistan’s are acutely aware of the costs at each stage of treatment. They are cutting corners to minimize costs, and this leads to suboptimal care in many settings. They are also tailoring treatment based on the patient’s ability to pay. This may work out in minor illnesses such as a simple upper respiratory infection, but can never work for a devastating and chronic illness such as cancer. Families must also make difficult choices when faced with expensive treatments in the palliative setting. Even in potentially curative settings, the multidisciplinary cancer care involving surgery followed by adjuvant chemotherapy and radiation treatment means that costs are prohibitive, and patients have to discontinue treatment when they run out of money.
Fortunately, patients and physicians in Canada will never face those problems. But it highlights one crucial point. Chronic illnesses such as cancer are very expensive to treat, and cancer care can never be given by private firms and insurance companies for profit. The ultimate focus of private enterprise is to make money, and investing in cancer care is like a bad investment that needs to be contained before it risks affecting the entire portfolio. In a society such as Canada, it would be unthinkable to leave the individual to bear the entire cost. The costs rightly fall under the provincial and federal departments of health.
One advantage of that approach is to remove monetary issues from the table during the physician–patient interaction. It is true that coverage is different in different provinces, but generally, within each health care system, everyone gets the same treatment. In the United States, treatment may depend on your insurance policy, with different plans providing different access to physicians and drugs. This leads to unnecessary anxiety for the patients. They are not sure if they are getting the perceived “best” treatment. There is a never-ending tussle between the patient and the insurance provider for this best treatment.
Treatment costs are skyrocketing. This is especially true for oncology. In an effort to control costs, insurance companies want to limit access to newer drugs. Expensive biologic therapy may add few weeks or months to the life of a stage iv metastatic cancer patient, but at a prohibitive cost. The initial meeting with an oncologist is an emotionally charged and complicated affair, and it need not be further complicated by adding the financial burden of disease on the patient’s shoulders. The best way to deal with this is not at the level of the individual patient, but at a societal level. The answers will be different for different societies and will depend on the economic strength of the region. It is easier for physicians to explain the relative lack of cost-effectiveness of a new and heavily marketed drug if nobody in the community is getting it.
The other major advantage of “socialized medicine” is that you don’t lose your health coverage with your job, nor are you prevented from considering a job switch because a pre-existing condition makes new health insurance unaffordable. Many people are forced to work through disease to keep their insurance benefits alive.
One of the major reasons industry is failing in the United States is rising health care costs. The price of each automobile produced in Detroit includes US$1600 for health and retiree costs. This was one of the main reasons for the growth of the auto industry in Ontario until recently. The rise of the loonie to parity with the U.S. dollar wiped out some of those benefits. The U.S. employers are now clamouring for a national health care plan 4 that at least partially transfers the cost to government-run plans. They are taking a closer look at the Canadian and European models. In the United States, there are 45.7 million uninsured. That is roughly 20% of the population and more than the entire population of Canada. Moreover insurance premiums are rising eight times faster than the average American income, making insurance increasingly unaffordable, even for working individuals 5.
The recent financial crisis and the health care debate in the United States has provided the right environment for supporting the Canadian social health care system. Private enterprise is a very potent force, but it is primarily driven by monetary concerns. This focus on maximizing profits eventually leads to greed. This model has problems in the truly capitalistic sections of the economy such as banking; it is unlikely to work well in the health care sector. Partially privatizing the system may lead to better outcomes in some sectors with well defined endpoints, but such privatization will leave the poor and people with chronic, resource-consuming illnesses as an expense of a weakened public system. There will be many hurdles in preserving and strengthening the current system. The health care industry lobby is particularly strong in Washington, and from time to time tries to enter into the Canadian debate about health care. Physicians should understand and appreciate the strengths of current Canadian system. Yes, there is room for improvement, but build on what already exists.