Commentary: Canada's Health Care System Isn't A Model Anymore

They are tales of a health-care system gone awry: A 10-year-old boy, Jean-Francois Giguere-Belisle, died in June, 1997, after his ruptured appendix went undiagnosed in two clinics and an emergency room. Jeyaraanie Kaneshakumar, 35 and pregnant, succumbed to a brain hemorrhage last fall after doctors couldn't find a neurosurgical facility that had room for her. Last September, Frances Lever, 49, died after her stomach pains, allegedly misdiagnosed after weeks of cancelled appointments, turned out to be cancer.

HMO horror stories? Not this time--these patients died in Canada. With its free care for all citizens and relative lack of bureaucracy, Canada's "single-payer" national health system has been proffered as the antidote to for-profit managed care, which has left more than 40 million people in the U.S. without medical insurance. But Canada's government-run complex is also growing distinctly unwell.

SQUEEZE. Federal and provincial governments are grappling with the fiscal duress caused by the near-tripling of real public-health spending from 1980 to 1990. Since the system sets no limits on demand, patients seek as much care as they can get, driving up costs. That has helped push total government debt to 90% of gross domestic product, vs. 45% in the U.S. Bureaucrats have had to ration supply by shutting hospitals, reducing medical payments, and limiting the hours doctors can spend in surgery.

As a result, service has plummeted, and physicians and patients are steaming. From Montreal to Vancouver, doctors--whose pay has barely budged since 1993--have staged or threatened job actions this year. On July 30, physicians across British Columbia shut their offices for five days and pledged to repeat the protest monthly. Virtually all obstetrician-gynecologists in Alberta, furious at the paltry $185 cap on the fee for a delivery, warn that they will opt out of the state system, forcing patients to pay for services. Critics charge that hospital closures have led to the deaths of patients who have been turned away from jammed facilities. And waiting lists for common procedures, which have always been protracted, have stretched even longer.

So as flu patients lie queued up on hospital gurneys and as some cancer patients wait more than two months for radiation treatments, critics argue that American-style, market-driven medicine may not be such a bad thing. Keep universal coverage, they say, but let Canadians pay for care if they want. "Create competitionand if the private sector performs better, then people will flock to it," says Dr. William J. McArthur, a fellow at the market-oriented Fraser Institute, a private think tank.

Supporters of the status quo worry that partial privatization will provide good care for the rich while shunting the poor to crowded, lower-quality facilities. Besides, most Canadians, who see universal health care as part of the national identity, "are very clear that they don't want an American system," says Hugh Armstrong, a professor at Carleton University School of Social Work.

FREEDOM TO CHOOSE. There are signs that market reform is inevitable. The Alberta government recently won a compromise allowing patients to go to private clinics for cataract surgery. Quebec's Institut de Cardiologie de Montreal wants to sell heart surgery to Americans. And in Calgary, private Health Resource Group Inc. has invested $2 million to refurbish a former government-funded hospital to serve third-party insured patients--typically, expatriates--and those covered by worker's compensation. "I want freedom for people to choose," says Dr. Stephen D. Miller, Health Resource's co-founder.

In the best of worlds, institutions would serve any Canadian with the means to pay. The poor and people with catastrophic ailments would be protected by requiring doctors who see paying patients to work in the public system as well. But first, argues medical student David Gratzer, a well-known critic of the system, "there has to be a recognition that something is wrong."

Americans might consider that as they look longingly north. Universal health coverage is an admirable intention. But a hybrid system that allows some competition may produce better care and lower overall cost--a model truly worth emulating.

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