Despite spending half what the U.S. does on health care, Canada doesn't
appear to be any worse at looking after the health of its citizens
By Christopher Mims
Whether it is American senior citizens driving into Canada in order to buy cheap prescription drugs or Canadians coming to the U.S. for surgery in order to avoid long wait times, the relative merits of these two
nations' health care systems are often cast in terms of anecdotes. Both systems are beset by ballooning costs and, especially
with a presidential election on the horizon, calls for reform, but a recent study could put ammunition in the hands of people
who believe it is time the U.S.
ceased to be the only developed nation without universal health coverage.
Gordon H. Guyatt, a professor of epidemiology and biostatistics at McMaster University in Hamilton, Ontario, who coined the term "evidence-based medicine," collaborated
with 16 of his colleagues in an exhaustive survey of existing studies on the outcomes of various medical procedures in both
the U.S. and Canada. Their work appears in the inaugural issue of the new Canadian journal Open Medicine,
and comes at a time when many in Canada
are debating whether or not to move that country's single-payer system toward for-profit delivery of care. The ultimate conclusion
of the study is that the Canadian medical system is as good as the U.S. version, at least when measured by a single metric—the rate at which patients in
either system died.
"Other people knew that Canadians live two to two and a half years longer than Americans,"
says Steffie Woolhandler, an author on the paper and an associate professor of medicine at Harvard Medical School, citing a phenomenon that many attribute to differences in lifestyle between the two countries. "But what was not
known was once you got sick, was the quality of care equivalent in the two countries."
Americans Less Likely to Survive Treatment
According to Woolhandler, by looking at already ill patients,
the researchers eliminated any Canadian lifestyle advantage and just examined the degree to which the two systems affected
patient deaths. (Mortality was the one kind of data they could extract from a disparate pool of 38 papers examining everything
from kidney failure to rheumatoid arthritis.)
Overall, the results favored Canadians,
who were 5 percent less likely than Americans to die in the course of treatment. Some disorders, such as kidney
failure, favored Canadians more strongly than Americans, whereas others, such as hip fracture, had slightly better outcomes
in the U.S. than in Canada. Of the 38 studies the authors surveyed, which were winnowed down from a pool of thousands,
14 favored Canada, five the U.S., and 19 yielded mixed results. {What the study misses is those in the U.S. who don’t get a hip replacement because they don’t have insurance.}
Mortality Isn't the Only Measure That Matters
Not all experts agree with the implication that the Canadian
system is better than the U.S. system, however, or with the researchers' methodology. Vivian Ho, who is the James A. Baker III Institute for Public
Policy chair in health economics at Rice University in Houston and has spent time living and conducting research in both the
U.S. and Canada, argues that the study's focus on mortality could be misleading.
"When we look at health systems we look at other things than death," Ho explains. In her
own research on hip fracture, which was cited in Guyatt's study, she found that the time a patient had to wait before surgery—which
was significantly longer in Canada
than the U.S. because of a shortage of operating rooms—made only
a 1 percent difference in terms of mortality.
"But certainly if you ask people waiting in the hospital," Ho notes, "They're going to
say I'd rather have the U.S.
system…. Waiting means there's a significant amount of distress for an elderly patient, and also higher complications
for pneumonia because you have the patient immobile for so long."
Patti Groome, an epidemiologist at Queens University Cancer Research Institute
in Kingston, Ontario, said she believes that overall the paper was balanced. "But when you get
into [the] meat of [the] paper they can't sort out what's going on…. There's way too much heterogeneity in these studies
to come to a conclusion about these systems." In meta-analyses such as this one, "heterogeneity" in results corresponds to
variations in the size of an effect across the studies being reviewed.
In other words, of the studies surveyed, some showed slightly better outcomes for the Canadian
system and some showed slightly better outcomes for the U.S. approach, making it hard to draw any conclusion other than that, on balance, the two systems seem to yield only slightly
different outcomes.
Money Doesn't Necessarily Buy Health
The study's authors highlight the fact that per capita spending on
health care is 89 percent higher in the U.S. than in Canada. "One thing that people generally know is that the administration costs are much higher in the U.S.," Groome notes. Indeed, one study by Woolhandler published in The New England
Journal of Medicine in 2003 found that 31 percent of
spending on health care in the U.S. went to administrative costs, whereas Canada spent only 17 percent on the same functions.
Ho believes, however, that there are also inefficiencies in the Canadian system. In her own work
on hip fracture, she found that Canadian hospitals held patients for longer periods because there was no incentive to discharge
them. "These patients are easier to take care of," she explains, "and that helps [hospital administrators] justify their budget….
I think there is room for economic incentives [in the Canadian system]."
"Personally," Ho adds, "my view is that the Canadian system is good for Canada and the American system is good for America. Neither side should switch, because the systems are a function of the population—the
Canadian population believes much more in maintaining social safety nets."
This research may already be having an impact on policy debate: According to Woolhandler, Ohio democratic congressman and presidential candidate Dennis
Kucinich has plans to circulate the results of this study to Congress. Woolhandler herself would like to see this study play
a part in a slightly different debate—one over whether it is better to be sick and insured in the U.S. or in Canada. "I'd like to see politicians giving
up on this mythology that the quality of care for sick people in the U.S. is unique."
WHAT ABOUT THOSE WITHOUT INSURANCE??? WHAT CARE
DO THEY GET. A friend of mine when he was 17 sat in the emergency room with the
humerus sticking through his skin in his arm with his parents because they didn’t have insurance. Two hours later their grandfather signed the necessary papers. Another
friend of mine—also without insurance--had treatment of his colon cancer delayed for 3 months because it took that long
for him to get approval of Medical for the indigent. That delay could well be
the cause of why his treatment failed--jk.
