That concept of having somebody else controlling a single spigot of resources that dictates convenience, or whether you can get to the best specialist, is simply something with which the American psyche is not comfortable.
Reviewing Canadian press coverage, you get a pretty dismal picture of America, and again, I’m not going to change that, especially with the 17 percent who voted “no” to the resolution. I think you are probably going to stick with what you believe. But I do want you to understand a little bit about how a pluralistic system works, and that it is rich and robust, and that it has benefits and advantages.
Our system is part socialized — our veterans’ system — and is single-payer for a large number of people through Medicare. I’ll come back and explain our Medicare and Medicaid.
In the U.S., we are the undisputed leader in biomedical research. We have a robust arsenal of prescription drugs as part of our Medicare plan. We have the best diagnostic and treatment technology in the world. And the good thing about it for the overwhelming majority of people is that it can be delivered more conveniently and with more certainty in the United States when you need it.
A quick primer on American health care: we’ve got a system that has about 42 million people on Medicare, which is a single-payer system run out of Washington, D.C., with a lot of price controls. We have a Medicaid system that has 47 million people. It is for low-income people, and not as complete as it should be. The new legislation adds another 16 million people to that over the next nine years. We have socialized health care in our system of veterans’ administration. And then we have 170 million people out there who get private health care insurance through private plans.
Let me say something about the uninsured in the U.S. Today there are 46 million uninsured. Of those, 30 million are completely uninsured. Now, it’s important to note that about 15 million of that 46 million earn more than 55,000 to 60,000 dollars a year and simply choose not to have health care insurance. If they need it they’ll go out and buy it.
My experience as a heart and lung transplant surgeon really introduced to me the single most important thing that would be lost if we went to a single-payer system, and that is our capacity to innovate. Our capacity to innovate is funded in large part because of an environment in which we do spend more on our health care, and in which there is a for-profit motive. It is a virtue, not a vice.
In America we put a high value on innovation; it is part of the American spirit. And that happens through a vibrant private sector. What’s the evidence? The U.S. produced eighteen of the last twenty-five Nobel laureates; thirty-two U.S. companies have developed half of all major new medicines introduced worldwide. And Americans played a key role in 80 percent of the most important medical advances over the last thirty years.
In America today you have access to the highest technology and the greatest biomedical research in the world.
RUDYARD GRIFFITHS: I’m now going to call on Robert Bell for his opening comments.
ROBERT BELL: Arguing against getting sick south of the border begins not with medical statistics, but rather by comparing bankruptcies in our two countries. Americans are nearly three times as likely to become bankrupt as Canadians, and the reason is medical bankruptcy.
David Himmelstein wrote in the American Journal of Medicine in 2009 that 62 percent of American bankruptcies were caused by an inability to pay medical bills. Surprisingly, he found that three-quarters of medical debtors had health insurance that proved inadequate to pay the bills in the face of a serious illness.
Nearly all medical statistics show better health outcomes in Canada. Johns Hopkins is an esteemed medical university in Baltimore, and their statisticians have compared national health results in Canada and the U.S. using Organisation for Economic Co-operation and Development [OECD] data. Life expectancy and infant mortality are better in Canada, health care costs 60 percent more in the United States, and, according to Johns Hopkins, Canadian patients live longer with cancer, heart disease, stroke, diabetes, and lung disease.
Furthermore, the Hopkins team found that the chance of dying from a medical error in an American hospital is 50 percent greater than in a Canadian hospital. So, if you get sick and you choose to go to the United States, you die sooner, you have a higher risk of fatal medical error, you pay at least 50 percent more, and if you are sick enough you go bankrupt.
However, rather than relying on statistics, let me tell you why as a surgeon I would rather look after sick patients in Canada than in the United States. I learned my specialty as a bone cancer surgeon at Massachusetts General Hospital, an affiliate of Harvard Medical School, and what I saw there made me come home to Canada to stay. Looking after teenagers with bone cancer in Boston was troubling. Black and Hispanic children frequently came to our clinic at a much later stage of disease, with large tumours that frequently required amputation rather than arm- or leg-salvaging surgery, or even after cancer had spread to their lungs.
This demonstrated the poor health equity outcomes evident even in Massachusetts, the most liberal state in the nation. This was also my first exposure to the inequity of American health insurance and health economics. Private insurance is the root of all evil, if you get sick, in America.
I used to be in charge of Princess Margaret Hospital, Canada’s leading cancer research centre, and I frequently visited The University of Texas MD Anderson Cancer Center, our counterpart in Houston, to exchange research ideas. Both hospitals treat about the same number of new patients. But there were two areas where there was a huge difference between the two hospitals: in the billing office and in chemotherapy treatment.
The billing office at Anderson had 500 employees furiously negotiating payment terms with multiple insurance companies. At that time, Princess Margaret employed one person in our billing office to collect for private rooms and televisions. Everything else was covered by our universal health insurance, showing why health care administration costs 3 percent in Canada compared to 13 percent in the United States.
Anderson also had more patients in chemotherapy treatment than at Princess Margaret, at least in part because of medical economics. U.S. cancer centres make a large profit from administering chemotherapy since they charge a substantial markup on chemotherapy drugs. This may explain why you are much more likely to get multiple courses of chemotherapy in America than in Canada, even though more lives are lost to cancer in the U.S., according to Johns Hopkins. The extra chemotherapy may not extend your life, but it sure makes big profits for the cancer hospital.
In closing, the U.S. has excellent health professionals; many of our doctors have studied — as I did — in the U.S. However, many American doctors come to Toronto, to Canada, to study with Canadian experts such as heart surgeon Dr. Tirone David at the Peter Munk Cardiac Centre. Dr. Frist himself is a cardiothoracic surgeon who practised lung transplant surgery prior to entering politics, and has told us during this debate about the importance of innovation and developing new therapies in transplants.
The senator knows, however, that the first successful single and double lung transplant operations in the world were done at Toronto General Hospital, and we continue to have the best results in the world in our University Health Network Multi-Organ Transplant Program.
Health care in both countries stimulates steamy debate. As Bill Maher recently said, “If conservatives get to call universal health care ‘socialized medicine,’ then I get to call private for-profit health insurers ‘soulless vampires making money off human pain.’” Those vampire insurers have launched a false information campaign against Canadian health care, suggesting that our patients wait for days in emergency departments and years for elective surgery.
In my final remarks I’m going to tell you the truth about Ontario wait times. And later tonight I’m going to introduce you to the man in this audience who has contributed more than any Canadian since Tommy Douglas to a sustainable health system in this country. But for now I want you to know that I am happy to work as a surgeo
n in a system that provides care based on patient need rather than insurance company and health care provider profit.
RUDYARD GRIFFITHS: David, you are up next.
DAVID GRATZER: By night, I’m a father and an insomniac. When my daughters are put to bed I like to write about health care policy. By day, I’m a physician and a Torontonian and I see patients in the Greater Toronto Area. Like so many physicians who work in Toronto I do the best I can to put my patients first. But too often I fear we have a system that puts politics first.
In countless decisions about technology, human resources, access to care itself, politics takes priority over the health care needs of our patients. Wait times are the best example of this. Over the last decade, three federal governments have demanded service guarantees and better wait times in exchange for new funding. The federal government’s own wait list watchdog insists that seven out of ten provinces — seven — have yet to deliver on those promises.
But the funding came through. In the last ten years Ontario’s health care spending has doubled, Nova Scotia’s has doubled, Alberta’s has tripled over eleven years, and yet what did we get for our money? In many cities patients still wait for the care they need.
To help you understand what waiting for surgery may feel like, let’s do a bit of a demonstration. I like to make things interactive. Is everyone ready?
First of all, introduce yourself to the person on your left. Now, here’s a quick anatomy lesson — and I’m a psychiatrist, so this is going to be a very quick anatomy lesson. Your knee has a big bone above it called the femur, and a little bone right under it called the tibia. And the stuff that holds all this together and makes it work is the cartilage. Now, lean over towards your neighbour to whom you’ve just introduced yourself and tear out the cartilage from their left knee.
Now you’ve got a lack of cartilage in your left knee and you have an understanding of why a knee replacement is so important. What you know is that now nights are going to be filled with pain, it will be difficult to walk and run and work and drive a car.
So here’s the good news. If you’re in rows A through Q raise your hands. Go ahead, raise your hands. Good news for you guys. According to the provincial government’s wait time data, we’ll fix your knee — if you go to Mount Sinai Hospital — by July 22. If you go to Sunnybrook Hospital it won’t be until November 16. If you go to Sir William Osler Health Centre it will be December 13.
Those of you in rows R through U will wait longer than we clinically recommend. If you’re from Markham, Ontario, you could wait past mid-January. Now, remember, this is all just a demonstration. But for those of us waiting for a knee replacement I want to point out that the wait times here in Ontario exceed all expectations by national and provincial standards. And this is a success story in the Canadian system — waiting months, possibly to 2011.
I could have picked more dire circumstances: cancer surgery in Hamilton, bypass surgery in Edmonton, hernia repair in Halifax. But I wanted to pick this example for a couple of reasons. First, seven out of ten provinces — seven — can’t even meet that standard which they had agreed to measure by their own data.
Secondly, I want to mention an academic paper. A team at Laval University looked at 197 patients waiting for knee replacement surgery in Ontario and Quebec in 2008 who were in so much pain and anxiety that they recommended pre-surgery rehabilitation and mental health services.
Here’s my point: we wait not only for knee replacements, we wait for practically everything in the Canadian system. You’ve heard time and again that a little bit of pain and anxiety is a small price to pay for the world’s best health care, and it’s free at the point of use. It isn’t necessarily free at the point of use anymore, and it’s not necessarily the best. You already know that the Americans do three times as many magnetic resonance imaging [MRI] scans as we do per capita, and twice as many computerized tomography [CT] scans.
What about positron emission tomography [PET] scanners? Some of you may not have even heard of it, it’s so obscure in Canada. In 2008 there was a study of colon cancer treatment3 showing half of doctors treated patients in Australia and New Zealand significantly differently after PET scan data. PET scans are only now being funded by OHIP, and I must point out that there were over 1,000 PET scanners in the United States by 2007.
Canada is even falling behind in key preventive measures. A joint Canada–U.S. survey of health found Americans have better access to preventive tests and higher treatment rates for chronic illness. We lag behind the U.S. and Europe when it comes to approving and insuring advanced drugs to treat cancer or rare disorders.
The political compromises that have been made are hazardous to your health. One way of comparing health care systems is to look at cancer outcomes. Five-year cancer outcomes in Canada — these are national statistics from a federal database — are 58 percent for men, and for American men it is 66 percent. For women there’s less of a spread — 62 percent versus 62.9 percent.
The American system is complicated and deeply flawed but it’s rich in resources, it’s rich in research capacity, professional capacity, and care capacity, and if you don’t believe me, your government certainly does. Ontario spent 164 million dollars last year sending our patients to their hospitals, because in the best health care system in the world we didn’t even have the capacity to care for our sick.
That’s not counting all of the people who are covered by OHIP and went to the United States hoping eventually the Canadian government would cover their care. There is, in a sense, a secret, private for-profit hospital here, and it’s called the United States.
RUDYARD GRIFFITHS: Mr. Dean, your opening statement, please.
HOWARD DEAN: We’ve heard a lot of things about these systems. Let’s talk about what the Americans think about their system. Sixty-five percent of the people in America like their health insurance. Thirty-five percent of Americans either don’t have any health insurance or have lousy health insurance where, if you should happen to get sick, you could lose your health insurance because they don’t have any obligation to keep it. So we may be able to understand why, at least for 35 percent of Americans, and you’ll have to guess which ones, Canada may be a much better place if you happen to get sick.
Now, there is a lot of talk about three times as many computerized axial tomography [CAT] scans done in the United States on a per capita basis. There are also three times as many coronary artery bypasses done on a per capita basis in the United States. If we start measuring the quality of our health care by how much gets done to you, I think we’re in trouble.
It may well be that those extra 200 percent of CAT scans and coronary artery bypass graphs are unnecessary medicine promoted by a pay-for-service system which is completely out of control in the U.S. It is safer to get sick in Canada because you may not have a whole lot of stuff done to you that is unnecessary medicine.
And why is there unnecessary medicine? It is because there’s the potential to make a lot of money when doctors can charge the insurance companies for all these procedures whether they work or not, or whether you need them or not.
And why are so many extra procedures carried out in the United States? Because we have a malpractice system that is very different than the Canadian system, and people like me are encouraged to do as many things as possible so we don’t see you in court and have to explain why we didn’t do all those tests. You are better off in Canada and your wallet is better off in Canada.
We know, from my esteemed colleague Dr. Bell, that your outcomes are better in Canada, embarrassingly even for child mortality, which is really a moral disgrace. You are less likely to have invasive procedures in Canada, which may not be necessary. In terms of waiting times, I’m about to have my hip replaced. I decided to do so eighteen months ago.
Many of the processes that require waiting time in Canada require waiting time because they don’t need to be done right away. I have no objection to having wealthy Canadians who want what they want imme
diately — which is an American disease — coming to the U.S. to have procedures. But if Canadians want a system which is 70 percent cheaper than ours and covers everybody, I think you are better off in the system that you have right now.
Is the U.S. health care system perfect? No. Is the Canadian health care system perfect? No. They both use pay-per-service medicine. That’s a substantial problem that drives costs up, and driving costs up is a huge issue in Canada and in the United States. But you are starting from a lower base in terms of what it costs and a much higher base in terms of how many people are covered, which in Canada is 100 percent. That makes this country better not only than the United States of America in terms of coverage but better than France, Britain, and better than many other countries which supposedly have universal health care.
Let’s talk about bureaucrats deciding what kind of health care people get. You say that politicians decide what kind of health care people get. I practised medicine for ten years. Not one time did I have to call my senator for permission to do a particular procedure, but I did have to call an insurance company bureaucrat who decided. They don’t have an RN, they don’t have an MD, and they’ve never seen a patient. Why are they telling me that I can’t do a procedure on a patient? They are telling me because they will make more money if I don’t. There is a profit incentive in the insurance system in the United States to do things that doctors think need to be done. I’ll leave it to you whether that happens in Canada, but you don’t have any health insurance companies, so I know an insurance company bureaucrat is not making those decisions for you.
Finally, let me just say that I would disagree with Senator Frist. The U.S. did not reject a single-payer system. We already have about 50 million people on a single-payer system. Our single-payer is bigger than your single-payer system. The mistake was we didn’t let people under sixty-five choose our single-payer system, which is Medicare.
The Munk Debates Page 19