So, Canada?

Canada’s system is sim­pler than Amer­ica’s patch­work of public and pri­vate plans, but there are draw­backs

The Washington Post - - FRONT PAGE - BY YAS­MEEN ABUTALEB

Amer­i­cans have ques­tions about Medi­care-for-all. Our neigh­bors to the north have an­swers.

When Bryan Keith was di­ag­nosed with prostate can­cer three years ago, he un­der­went a blizzard of tests, spe­cial­ist con­sul­ta­tions, a month of ra­di­a­tion treat­ment and a sur­gi­cal pro­ce­dure.

His out-of-pocket costs? Zero. “I’ve never had to reach into my wal­let for any­thing other than my health-care card,” said Keith, 71, who is now in re­mis­sion.

In this pic­turesque moun­tain town of about 10,000 peo­ple, Keith’s ex­pe­ri­ence is the norm — and the model of­ten cited by Sens. Bernie San­ders and El­iz­a­beth Warren as they pro­mote Medi­care-for-all as an an­ti­dote to some of the prob­lems af­flict­ing U.S. health-care con­sumers.

No one in this mostly work­ing-class com­mu­nity ag­o­nizes over whether they can af­ford to see a doc­tor, or take their child to the emer­gency room. No one faces bank­ruptcy, or loses their home, be­cause of med­i­cal debt. Most res­i­dents of Hin­ton have had ba­bies de­liv­ered, bro­ken bones set and can­cer treat­ments pro­vided with­out ever see­ing a bill.

But there are also draw­backs: Some wait months for knee or hip re­place­ments or to see cer­tain spe­cial­ists. Most also pay pre­mi­ums for pri­vate in­surance to cover pre­scrip­tion drugs and other ser­vices not in­cluded in their govern­ment plan.

As mid­dle-class Amer­i­cans ex­press grow­ing anger about sky­rock­et­ing drug prices and mount­ing co-pays, pre­mi­ums and de­ductibles, the Cana­dian health­care system has emerged as a shadow player in the 2020 Demo­cratic pres­i­den­tial pri­mary con­test — of­fer­ing a win­dow onto a par­al­lel re­al­ity where 37 mil­lion peo­ple’s health-care needs are largely cov­ered from birth to death.

The sto­ries of real peo­ple here in ru­ral Al­berta show how the health-care system func­tions in their daily lives — and un­der­score Cana­di­ans’ deep and widely shared be­lief that health care is a hu­man right, which helps ex­plain their over­whelm­ingly pos­i­tive reviews of the system de­spite its short­com­ings.

By all ac­counts, Canada’s system, called Medi­care, is sim­pler, more eq­ui­table and more con­sumer-friendly than Amer­ica’s patch­work of public and pri­vate plans that leaves mil­lions with­out suf­fi­cient cov­er­age. Ev­ery res­i­dent of Canada has guar­an­teed ac­cess to cov­ered ben­e­fits through provin­cial- and ter­ri­to­rial-ad­min­is­tered public in­surance plans

— and pays taxes to sup­port that system. There are no pre­mi­ums, co-pays or de­ductibles for a broad menu of care that in­cludes doc­tor vis­its, emer­gency care, hos­pi­tal stays, sur­gi­cal care, and ma­ter­nal and new­born ser­vices.

No­tably, the system is far less gen­er­ous than what San­ders (I-VT.) and Warren (D-mass.) have pro­posed. Key ser­vices that are not part of the public plans (but are part of San­ders’s bill) in­clude pre­scrip­tion drugs and vi­sion, den­tal and re­ha­bil­i­ta­tion ser­vices, with de­tails vary­ing by prov­ince. About two-thirds of Cana­di­ans also have sup­ple­men­tal pri­vate in­surance, typ­i­cally through their em­ploy­ers, to help with those costs and for which they do pay pre­mi­ums.

Canada’s system has its own headaches, from slower adop­tion of cut­ting-edge tech­nol­ogy and treat­ments to long waits to see cer­tain spe­cial­ists or un­dergo elec­tive pro­ce­dures, es­pe­cially hip and knee re­place­ments and cataract surgery. And Canada is fac­ing some of the same fi­nan­cial pres­sures be­dev­il­ing the United States — es­pe­cially the snow­balling costs of car­ing for an ag­ing pop­u­la­tion. A govern­ment panel in Al­berta con­cluded this year that the prov­ince’s health system is a top con­trib­u­tor to its un­sus­tain­able spend­ing.

Nev­er­the­less, res­i­dents of ru­ral Hin­ton give their system high marks, with sev­eral re­count­ing com­plex med­i­cal or­deals that cost them nearly noth­ing out of pocket — but that might have set back Amer­i­can con­sumers by thou­sands or tens of thou­sands of dol­lars, de­pend­ing on their cov­er­age.

There was Sa­man­tha Ellen Gor­don’s pre­ma­ture daugh­ter who needed three surg­eries and a nearly six-month hos­pi­tal stay two years ago, and then the May de­liv­ery of her sec­ond daugh­ter via emer­gency Cae­sarean sec­tion. There was Rick Zroback’s eye surgery to re­move “floaters,” or spots in his vi­sion, and Mor­ris Archibald’s full hip re­place­ment. And there were He­lena Chris­tensen’s C-sec­tions, and mul­ti­ple emer­gency room trips with one of her sons, in­clud­ing a three-week hos­pi­tal stay for pneu­mo­nia.

“I would have never been able to have three kids in Amer­ica be­cause I needed all C-sec­tions,” Chris­tensen said. “I like the free­dom that you can go to the doc­tor and not worry about the cost.”

While tak­ing com­fort — and pride — in their system’s univer­sal cov­er­age, Hin­ton res­i­dents also ac­knowl­edge con­cerns, chief among them the de­lays to see spe­cial­ists or to un­dergo cer­tain types of non-emer­gency surg­eries.

Mor­ris Archibald, 66, a re­tired forester, waited nearly a year for his hip re­place­ment. He said he could not walk a block, and he grew de­pressed be­cause he could not par­tic­i­pate in the out­door sports he loves and that are his main pas­time. “It got to the point where we wor­ried about his state of mind,” Jodi Archibald said.

The cou­ple even ex­plored hav­ing the surgery in the United States but aban­doned that idea af­ter dis­cov­er­ing that it would cost tens of thou­sands of dol­lars.

De­spite that ex­pe­ri­ence, Mor­ris Archibald said he would never trade his Cana­dian health care for U.S. health in­surance. “I still think our system is far su­pe­rior,” he said.

Archibald’s wait is hardly unique: Thirty-nine per­cent of Cana­di­ans re­ported wait­ing at least two months to see a spe­cial­ist, a JAMA anal­y­sis of 2016 data found, com­pared with 6 per­cent of Amer­i­cans. The United States also has more spe­cial­ists as a per­cent­age of its to­tal health work­force.

Those waits cost Cana­di­ans $2.1 bil­lion in lost wages in 2018, with av­er­age wait times about 20 weeks from re­fer­ral to re­ceipt of treat­ment — 113 per­cent longer than in 1993, ac­cord­ing to stud­ies this year by the con­ser­va­tive Fraser In­sti­tute, a public pol­icy think tank in Canada.

“Meekly ac­cept­ing ex­ces­sive wait times as the price of a func­tion­ing health care system in Canada is the ex­act op­po­site of what we should be do­ing,” the Toronto Sun ed­i­to­ri­al­ized af­ter the stud­ies were re­leased.

Even so, Canada has bet­ter health out­comes than the United States while spend­ing far less on care. Cana­di­ans’ life ex­pectancy is 82 on av­er­age — more than three years longer than Amer­i­cans’, ac­cord­ing to a 2019 re­port from the Or­ga­ni­za­tion for Eco­nomic Co­op­er­a­tion and De­vel­op­ment (OECD) based on 2017 data. It also boasts a far lower rate of deaths from treat­able causes, at 59 per 100,000 res­i­dents, com­pared with 88 per 100,000 res­i­dents in the United States. The in­fant mor­tal­ity rate in Canada is 4.5 per 1,000 live births, com­pared with the U.S. rate of 5.8.

‘Ev­ery pa­tient is a pay­ing pa­tient’

“I like the free­dom that you can go to the doc­tor and not worry about the cost.”

He­lena Chris­tensen

Canada’s ex­pe­ri­ence also de­fies the no­tion that a sin­gle-payer system would dis­rupt Amer­ica’s al­ready shaky ru­ral health system. In fact, Canada’s ru­ral hos­pi­tals ap­pear to strug­gle far less than their U.S. coun­ter­parts, more than 100 of which have closed since 2010.

“In a sin­gle-payer system, ev­ery pa­tient is a pay­ing pa­tient,” said Michael Green, one of the ed­i­tors of the Cana­dian Jour­nal of Ru­ral Medicine and head of the depart­ment of fam­ily medicine at Queen’s Univer­sity.

Hos­pi­tals’ bud­gets, staffing and equip­ment in Canada are set by provin­cial gov­ern­ments, which make those de­ci­sions based on a com­mu­nity’s size and needs, rather than on whether a hos­pi­tal can bring in enough rev­enue from pri­vate and public in­surance to keep its doors open, as in this coun­try. Ru­ral hos­pi­tals oc­ca­sion­ally close, but it’s usu­ally be­cause of chal­lenges in recruiting doc­tors to far-flung towns or be­cause a fa­cil­ity has low oc­cu­pancy rates that no longer jus­tify the cost of keep­ing it open. Hos­pi­tals are also sus­cep­ti­ble to na­tional or provin­cial bud­getary woes — sev­eral ru­ral hos­pi­tals closed in the 1990s in Saskatchew­an as a re­sult of a re­ces­sion — but politi­cians typ­i­cally face fierce pres­sure from con­stituents to pro­tect their health-care ser­vices.

By com­par­i­son, “ru­ral health care in the U.S. is a train wreck,” said Lee Green, chair of the depart­ment of fam­ily medicine at the Univer­sity of Al­berta, who was a pro­fes­sor at the Univer­sity of Michi­gan for 26 years. “Sin­gle­payer would be the best thing that ever hap­pened to ru­ral hos­pi­tals and ru­ral fam­ily doc­tors in Amer­ica — not to men­tion the pa­tients.”

The tax levels that sus­tain the Cana­dian system at the fed­eral level aren’t that dif­fer­ent from those in the United States. The United States on av­er­age col­lected $14,794 in taxes from each of its ci­ti­zens in 2015, while Canada col­lected $13,771, ac­cord­ing to the OECD. Direct com­par­isons of U.S. and Cana­dian tax rates are dif­fi­cult be­cause it is un­clear what por­tion goes into health care, which is ad­min­is­tered in both coun­tries by the fed­eral govern­ment as well as state or provin­cial gov­ern­ments, and taxes dif­fer by state, prov­ince and city.

None­the­less, graft­ing Canada’s system onto Amer­i­can soil would be dif­fi­cult for a gamut of cul­tural, eco­nomic and po­lit­i­cal rea­sons.

Al­berta leans con­ser­va­tive in Cana­dian pol­i­tics, for in­stance, but the idea of health care as a hu­man right is widely shared. A 2016 poll found that 87 per­cent of Cana­di­ans ranked health care as a top fed­eral pri­or­ity, and a ma­jor­ity said they would like to see the fed­eral govern­ment in­crease its in­volve­ment.

“I re­ally don’t un­der­stand why some peo­ple feel more en­ti­tled to health care than other peo­ple,” said Keith, the can­cer sur­vivor.

Con­trast that con­sen­sus with at­ti­tudes in the United States, where the very no­tion of govern­ment re­spon­si­bil­ity for health care is di­vi­sive. “More than eightin-ten Democrats and Demo­cratic-lean­ing in­de­pen­dents (85%) say this re­spon­si­bil­ity falls to the fed­eral govern­ment,” ac­cord­ing to a 2018 na­tional sur­vey by the Pew Re­search Cen­ter. “About twothirds of Repub­li­cans and Repub­li­can lean­ers (68%) say it does not.”

The Cana­dian system is also far bet­ter able to rein in costs be­cause of its em­pha­sis on pri­mary care rather than on spe­cial­ists, or on com­plex and costly pro­ce­dures — an ap­proach un­likely to be ac­cepted in the United States. The govern­ment also sets pay­ment rates for hos­pi­tals and doc­tors, most of whom are pri­vate, and ne­go­ti­ates drug prices di­rectly with man­u­fac­tur­ers. In the United States, by con­trast, en­trenched and pow­er­ful in­dus­try groups op­pose govern­ment price­set­ting — and are al­ready mo­bi­liz­ing against the plans ad­vanced by San­ders and Warren.

‘We did not pay a sin­gle penny’

All of those fac­tors help shape the care de­liv­ered by this com­mu­nity’s sole hos­pi­tal, the Hin­ton Health­care Cen­ter, a mod­est brick build­ing that sits less than two miles down a wind­ing road from the town’s pulp mill, past rolling green hills and snow­capped moun­tain ranges. Many of its pa­tients are work­ing class — em­ployed by the pulp mill, one of two lo­cal coal mines, or the oil and gas in­dus­try.

Hin­ton is too small to jus­tify the cost of most spe­cial­ists, so like most ru­ral hos­pi­tals, the cen­ter re­lies on fam­ily doc­tors like An­drea Rahn, who can be a pe­di­a­tri­cian, gen­eral prac­ti­tioner, ob­ste­tri­cian and emer­gency room physi­cian, some­times all in the same day.

The com­mu­nity has four fam­ily doc­tors who de­liver ba­bies — and three of them, in­clud­ing Rahn, also do ob­stet­ric surgery. Two have ex­tra train­ing in anes­the­sia, so they han­dle all of the anes­the­sia for the hos­pi­tal’s surg­eries. And two staff the hos­pi­tal’s can­cer clinic and pro­vide chemo­ther­apy ser­vices in con­junc­tion with an on­col­o­gist in Ed­mon­ton, Al­berta’s cap­i­tal, about a three­hour drive away.

The health cen­ter is also one of Canada’s few ru­ral hos­pi­tals with a CT scan, which serves those in neigh­bor­ing com­mu­ni­ties as well.

An MRI bus vis­its town about once a month, and var­i­ous spe­cial­ists come through ev­ery four to six weeks. Hin­ton doc­tors also use telemedici­ne to quickly get help from spe­cial­ists if they need it, like the time a neona­tol­o­gist in Ed­mon­ton was on TV pro­vid­ing in­struc­tions on how to treat a pre­ma­ture baby. In Au­gust, a vis­it­ing or­tho­pe­dic sur­geon was in town for two days to per­form pro­ce­dures and con­sult with pa­tients.

About half of Canada’s doc­tors are fam­ily doc­tors, com­pared with about a third in the United States, ac­cord­ing to the Com­mon­wealth Fund. Most are pri­vate and get paid for ev­ery pro­ce­dure or of­fice visit. Sev­eral of the coun­try’s med­i­cal pro­grams have ru­ral tracks, where stu­dents train as fam­ily doc­tors in ru­ral set­tings and can re­ceive ad­di­tional train­ing in other spe­cial­ties so they can han­dle any­thing that comes through the hos­pi­tal’s doors.

Rahn got such an op­por­tu­nity May 28. She was fin­ish­ing up clinic vis­its when she got a call from Gor­don, 27, who was days away from a sched­uled C-sec­tion. “Pain, pain, pain” were the only words Rahn could un­der­stand.

Rahn knew, based on Gor­don’s med­i­cal his­tory, that her uterus had prob­a­bly rup­tured. She and 20 other doc­tors, nurses and tech­ni­cians met Gor­don at the hos­pi­tal and per­formed an emer­gency C-sec­tion. The baby, An­nie, wasn’t breath­ing when they de­liv­ered her. They per­formed CPR and chest com­pres­sions, gave her a blood trans­fu­sion, and be­gan a cool­ing treat­ment for in­fants who do not have enough oxy­gen at birth. Af­ter nearly five hours, Gor­don and An­nie were sta­ble enough to be flown by air am­bu­lance to Ed­mon­ton for more spe­cial­ized treat­ment.

“That was the first time I’ve done that surgery,” Rahn said of per­form­ing a C-sec­tion on a woman with a rup­tured uterus.

Gor­don had trau­matic de­liv­er­ies for both her daugh­ters. The first, Amelia, was born April 5, 2017, 17 weeks pre­ma­ture, weigh­ing 1 pound and 3 ounces, and had a twin brother who didn’t sur­vive.

Amelia spent the next 168 days in Ed­mon­ton’s neona­tal in­ten­sive-care unit. Gor­don and her fi­ance, now a heavy-duty me­chanic at the town’s pulp mill, had no out-of-pocket med­i­cal costs for her care, or for An­nie’s. But his costs driv­ing three hours to and from Ed­mon­ton ev­ery week­end and buy­ing meals at the hos­pi­tal added up over sev­eral months. The Hin­ton com­mu­nity or­ga­nized a fundraiser for them and brought in $8,000.

To­day, Amelia is a ram­bunc­tious tod­dler who can’t stay still. She and An­nie have vis­its with spe­cial­ists ev­ery few months to make sure they’re de­vel­op­ing nor­mally.

“Even with the fundraiser, we still had debt from gas and food,” Gor­don said. “As far as care, we did not pay a sin­gle penny.”

PHO­TOS BY AM­BER BRACKEN FOR THE WASH­ING­TON POST

TOP: Sa­man­tha Ellen Gor­don with daugh­ters An­nie, then 3 months, and Amelia, 2, right sil­hou­ette. The girls’ births in­volved se­ri­ous is­sues. ABOVE: Hin­ton Health­care Cen­ter strug­gles less than many of its ru­ral U.S. coun­ter­parts, in part be­cause “ev­ery pa­tient is a pay­ing pa­tient.”

PHO­TOS BY AM­BER BRACKEN FOR THE WASH­ING­TON POST

FROM TOP: A pop­u­lar na­ture trail in Hin­ton, a moun­tain com­mu­nity where many of the 10,000 res­i­dents work for the lo­cal pulp mill, a pair of coal mines, or the oil and gas in­dus­try. The Hin­ton Health­care Cen­ter is equipped to han­dle emer­gen­cies and of­fers dial­y­sis, chemo­ther­apy and some surg­eries. An­drea Rahn is a fam­ily prac­ti­tioner at the Hin­ton Health­care Cen­ter. Sa­man­tha Gor­don, 27, with her daugh­ter Amelia, 2, who spent 168 days in a neona­tal in­ten­sive-care unit af­ter be­ing born pre­ma­turely.

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