What can the US learn from Canada s health

What can the US learn from Canada’s health system Michael M. Rachlis MD MSc FRCPC www. michaelrachlis. com Progressive Democrats of America June 16, 2009

Outline • Introduction to Canada and its health care system • Canada’s health system’s problems, diagnosis, and solutions • What can the US learn from Canada?

Tommy Douglas

(All data from Canada CIA World Fact Book 2009) USA Population 33 million 307 million 82 million Area 9, 984, 670 km 2 9, 826, 630 km² 357, 021 km 2 GDP ($US PPP) $39, 300 $47, 000 $34, 800 Gini coefficient 32 45 27 (Lower = more equality) 2005 data Germany

(All data from Canada CIA World Fact Book 2009) USA Germany Infant mortality 5. 0/1000 6. 3/1000 4. 0/1000 Life Expectancy F 83. 91 M 78. 69 F 80. 69 M 75. 65 F 82. 42 M 76. 26 Migrants 5. 6/1000 4. 3/1000 2. 2/1000 Birth rate 10. 3/1000 13. 8/1000 8. 2/1000 % > 65 15. 2% 12. 8% 20. 3%

Canada: Political Organization • Westminster model of government • Ten provinces and three territories • The federal government is responsible foreign affairs, defense, and criminal law • The provinces are responsible for health care, education, and social services • Quebec has special status

Canada: Political Organization • The federal government and the provinces share authority over public health, the environment, and other key policy areas • Canadian governments fight constantly – Have you seen us play hockey?

Canada’s Health Insurance • Federal health insurance legislation sets standards for provincial insurance coverage for physicians and hospital care only • Mandated first dollar coverage for hospitals and physicians’ services • Mixed public private coverage for pharmaceuticals, long-term care, home care, and durable medical equipment • Mainly private coverage for dental, optical • Except for hospitals and doctors, coverage varies substantially from province to province

Canada’s Health Insurance history • 1947 Saskatchewan legislates hospital insurance • 1957 Federal government legislates national hospital insurance mandating provincial plan principles • 1962 Saskatchewan legislates doctors’ insurance • 1968 Federal government legislates national doctors’ insurance mandating provincial plan principles • Late 1970 s and early 1980 s doctors and hospitals in several provinces begin to extra-bill patients beyond the public insurance tariff • 1984 Federal government legislates the Canada Health Act banning extra-billing

Canada Health Act principles • Universality – All Canadian residents must be covered • Comprehensiveness – All “medically necessary” physicians and hospital services must be covered • Accessibility – No user charges for insured services • Public Administration • Portability

Canada’s Health Care System • Not “Socialized Medicine” • Canadian health care, like other aspects of our social policy, is “mid-Atlantic” • Canadian Medicare is characterized by “Private Practice: Public Payment” (CD Naylor. 1986) – Most doctors are self-employed and bill provincial health plans on a fee-for-service basis • In most provinces, regional health authorities own and run hospitals, long-term care, home care, mental health, and public health

OECD Health Data Canada USA 2008 (Most data from 2006/7. Germany Health $ (GDP %) 10. 0% 15. 3% 10. 6% Public % of HC $ 70. 7% 44. 5% 76. 9% http: //www. irdes. fr/Eco. Sante/Do wn. Load/OECDHealth. Data_Freque ntly. Requested. Data. xls) Health US $/capita $3678 $6714 Practicing MDs 2. 1/1000 2. 4/1000 $3371 3. 5/1000 Practicing RNs MRI Units/million 8. 1/1000 10. 5/1000 9. 8/1000 6. 2 26. 5 7. 7 Acute care beds 2. 8/1000 2. 7/1000 6. 2/1000

General Gov't Outlays (From http: //www. fin. gc. ca/frt/2008/frt 08_e. pdf) 50 40 30 20 Canada 10 US 06 20 03 20 00 20 97 19 94 19 91 19 88 19 85 19 82 19 79 19 76 19 73 0 19 Percent of GDP 60

Canada vs. the US: No contest! • In the 1950 s, Canada & US had the same health system, the same costs, and the same health • Now all Canadians are covered but 47 million Americans are uninsured, and tens of millions more are under-insured • Canada spends much less than the US • Canadians get only slightly fewer services overall • Canadians live 3 years longer than Americans and our infant mortality rate is 20% lower. • Our Medicare boosts Canadian business – Health care costs are 1. 5% of Canadian manufacturers’ payrolls vs. 9% in the US

Health Exp as % of GDP (From: http: //www. oecd. org/document/16/0, 3343, en_2649_34631_2085200_1_1, 00. html ) 18. 0 16. 0 12. 0 10. 0 8. 0 6. 0 Canada 4. 0 USA 2. 0 04 20 00 20 96 19 92 19 88 19 84 19 80 19 76 19 72 19 68 19 64 19 60 0. 0 19 % GDP 14. 0

S Woolhandler Int J H Serv 2004; 34: 65 -78.

Canadian health care costs, especially public costs are not out of control

Canadian Health Exp as % of GDP (NHEX 2008) 12 8 6 4 2 0 Total HC as % of GDP Prov/Terr HC as % of GDP 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 % of GDP 10

Canada’s health system’s problems, diagnosis, and solutions

Canadian Medicare was designed for another time and was a compromise 1. It was designed for acute illness and Canada’s acute care system compares well internationally 2. But now the main problems are chronic diseases and Canada does poorly with these and with waits and delays. 3. Political compromise slowed the development of a more effective delivery system

AUS CA DEU NZ UK US 3. 5 5 2 3. 5 1 6 Quality of Care 4 6 2. 5 1 5 Right care 5 6 3 4 2 1 Safe care 4 5 1 3 2 6 Coordinated care 3 6 4 2 1 5 Patient-centered care 3 6 2 1 4 5 Access 3 5 1 2 4 6 Efficiency 4 5 3 2 1 6 Equity 2 5 4 3 1 6 Healthy Lives 1 3 2 4. 5 6 $2876 $3165 $3005 $2083 $2546 $6102 Overall Rank US$/Capita (PPP) Chronic Disease Care. K. Davis et al Commonwealth Fund pub no 1027 May 2007

Political compromise slowed the development of a more effective delivery system

The original Saskatchewan vision -- Swift Current in 1945 – similar to the Group Health Cooperative of Puget Sound in 1948 • Prepaid funding Services available on a universal basis, with little or no charge to users. • Integrated health care delivery including acute care, primary care, home care, and public health. • Group medical practice with doctors working in teams with nurses and other providers. Overall public health view of the system. • Democratic community governance of health care delivery by local boards.

What happened to the vision? • Despite the Swift Current Region’s success, Saskatchewan MDs in the 1950 s wanted independent practice paid on fee for service • 90% of doctors strike when the province simply legislates public insurance in 1962

What happened to the vision? • The federal government only covered hospital and medical care leaving coverage incomplete • Dr. John Hastings’s 1972 Report recommended reorganizing the delivery system but it’s mainly ignored – The models that were implemented prove to be fonts of innovation • Canada inspires other countries’ health policies but not our own

What happened to the vision? • 1990 s cutbacks harm a vulnerable system • Waits and delays worsen • The 2005 Supreme Court Chaoulli case reopens the debate about private health care • Reforms are being implemented and some places have made significant progress

We need to change the way we deliver services “Removing the financial barriers between the provider of health care and the recipient is a minor matter, a matter of law, a matter of taxation. The real problem is how do we reorganize the health delivery system. We have a health delivery system that is lamentably out of date. ” Tommy Douglas

“Only through the practice of preventive medicine will we keep the costs from becoming so excessive that the public will decide that Medicare is not in the best interests of the people of the country. ” Tommy Douglas

Canadians could have quicker access • Saskatchewan is aiming for 30% of family practices on same day service this year and 100% by 2010 • The Hamilton Shared care Mental Health Program increased access for mental health patients by 1100% while decreasing referrals to the psychiatry outpatients’ clinic by 70%. • The Alberta Bone and Joint Health Institute reduced the delay for joint replacements from 82 weeks to 11 weeks from GP referral to implantation of the new joint

What can the US learn from Canada? • Only public health insurance can control costs AND provide universal access • Public health insurance is business’s best friend • Public health insurance improves equity and efficiency but does not automatically lead to improved quality • Primary health care is the most important part of any health system. Canada’s poor international performance for chronic disease management and waits and delays is due to inadequate PHC

What can others learn from Canada? • Canada’s system has slowly evolved since the 1960 s • Canada’s health care policy-making is more complicated than pre-World War I European diplomacy! • Be careful about news from abroad

Summary • Canada has 14 health care systems • Canadian Medicare greatly outperforms the US system • The US can learn from Canada: – Single payer systems control costs while providing universal access – But you need to re-organize the delivery system to improve quality

Courage my Friends, it is Not Too Late to Make a Better World! Tommy Douglas