Proudly Canadian

Richard Reznick

In October 2009, at the annual congress of the American College of Surgeons, Robin McLeod, a Regent of the ACS, organized a symposium on the Canadian Health Care system. The room was packed, predominantly with American surgeons. By coincidence, as we were speaking, the U.S. Senate was voting on Obama's health care reform bill.

The speakers, Rich Finley from the University of British Columbia, Bill Fitzgerald President of the Royal College, Hugh Scully from University of Toronto and I were poised for a backlash of anti-Canadian health care sentiment. After all, these past few months have seen a lot of scare-mongering propaganda, such as rumours of Canadian Death panels (1) and claims that Canadian doctors are deserting the profession en masse (2).

To our amazement, the reception we received was exactly the opposite. Our surgical colleagues were profoundly interested in our comments, by and large not very knowledgeable of our system, and somewhat in awe of the messages they received. Without question, most in the room left with what we believe is the right information; that Canadian surgeons are for the most part very pleased with our system and academic health care in Canada is thriving.

THE MESSAGES

The four speakers described the Canadian health care system with a focus on the academic health science centre. We emphasized that the Canada Health Act ensured Canadians of a system that is universal, portable, accessible, comprehensive and publicly administered. Rich Finley commented on the fact that when polled on who they most respected, more Canadians mentioned Tommy Douglas, the father of Medicare, than any other figure. Roy Romanow, in his 2002 report articulates what many Canadians feel about our system: "the principles of the Canada Health Act began as simple conditions attached to federal funding for medicare. Over time, they became much more than that. Today, they represent both the values underlying the health care system and the conditions that governments attach to funding a national system of public health care. The principles have stood the test of time and continue to reflect the values of Canadians."

Our audience was especially interested in the differences between the Canadian and the U.S. systems. We acknowledged that those Americans who are insured enjoy better and more immediate access to health care services. Further, we underscored that repeated public opinion polls increasingly have shown that the greatest concern Canadians have about the existing publicly funded health care system is the perceived waiting times for diagnostic services, hospital care, and access to specialists. But better access to services in the U.S. comes at a dramatic cost. Some of these costs are easy to calculate, such as the fact that we spend roughly 10% of our GDP on health care whereas America spends 15%. Some of the costs are more difficult to put a value on, such as Canadians' immunity from financial devastation if they become ill and the stark reality that 40 million Americans are uninsured or under-insured. We spoke of the costs of administering our health care system, which are a fraction of the costs in the U.S. For example, most Canadian surgeons have one secretary who does all of the surgeon's billing as a small part of the job. In contrast, it is not uncommon for an American surgeon to employ three or more individuals whose sole job is to negotiate payments with insurance companies and administer a complex billing process. We were asked what our average receipts were for every dollar billed. When we answered roughly 99 cents on the dollar, our American colleagues were flabbergasted. The American system is so unwieldy that Blue Cross of Massachusetts employs more people to administer coverage for 2.5 million New Englanders than are employed in all of Canada to administer single payer coverage for 27 million Canadians.

But does the American health care dollar buy better health? The answer is essentially no. Gord Guyatt, in a systematic review of studies comparing health outcomes in Canada and the United States, examined 10 recent "high quality" studies. He reported that of the ten, five favoured outcomes in the Canadian system, two favoured outcomes in the American system and three were equivocal (4).

The myth that Canadian doctors are escaping to the U.S. in droves still persists. I believe we dispelled that myth. Data from the Canadian Institute of Health Informatics show that the "brain drain" reversed in 2004. In 2001, 555 physicians left Canada whereas 334 returned. In 2004, 262 left and 317 returned and in 2005 185 left and 247 returned.

We also addressed the issues of governmental involvement in patient care. We emphasized that in our system patients choose their own doctor and the government does not participate in day-to-day care, nor do they collect any individual patient information. We took pains to indicate that everyone in our system receives the same level of care. Finally we stressed that when polled 86 % of Canadians supported or strongly supported public solutions to make our public health care stronger.

A fair bit of the discussion was philosophical. We questioned what the barometers were of a civilized society and opined that one measure is the ability of a nation to look after its sick. We questioned the right of insurance companies to make large profits on the unfortunate victims of illness. We underscored that Canada's health care system, which fully looks after 32 million people, costs roughly what the private-sector health insurance companies make in profits in the United States. And we talked of the medical mal-practice culture in the U.S. compared to Canada. In the U.S. it is estimated that court costs and judgments add 2 to 3% of GDP to the total medical tab (5).

Our American colleagues were stunned when we reported the incomes of Canadian surgeons in the academic sector. Without question, our surgeons are making a much better living than they would as academic clinicians in just about any American jurisdiction. With a gross income of $335,000 (2006 CMA data), approximately $100,000 in salary support for a new academic recruit, a minimum of 20% protected time, average oncall duties of one in six, virtually no time spent on sourcing work, and malpractice premiums of $12,000 -- by all measures, Canadian surgeons are doing well.

Finally, we discussed training and the looming HHR crisis in both our countries. While both nations are under the same strain with respect to physician shortages, we are much better positioned to respond to this problem. The root of the difference is the Balanced Budget Amendment in the U.S. which has ostensibly thwarted growth of residency programs. In contrast, Canada-wide, the numbers of surgical residency positions has grown from 1350 in 05-06 to 1550 in 08-09; an increase of 15%.

After one and one half hours of talks and a robust and animated question period, the session closed. All five of us, McLeod, Finley, Fitzgerald, Scully and Reznick remained for a long time to accommodate individuals who had additional questions for us. We were overwhelmed by their interest, upset by the depth of concern many expressed about their own system and immeasurably proud to be Canadian.

Richard K. Reznick
R. S. McLaughlin Professor and Chair

(1) http://thecaucus.blogs.nytimes.com/2009/08/18/death-panels- arent-the-half-of-it-says-senator-kyl/: accessed Nov. 9, 2009

(2) http://www.google.com/hostednews/canadianpress/article/ALeqM 5jRNEXbCDOJNCa_L56GCMqRDYehmw : accessed Nov. 9, 2009

(3) www.hc-sc.gc.ca/hcs-sss/hhr-rhs/strateg/romanow-eng.php: (accessed Nov. 8, 2009)

(4) Guyatt GH, Devereaux PJ, Lexchin J et al. A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine, Vol 1, No 1 (2007)

(5) http://network.nationalpost.com/np/blogs/francis/ archive/2009/05/12/health-care-lies-about-canada.aspx : (accessed Nov. 9, 2009)