People in the Tea Party were saying government is too big, and we hate the government — but keep the government’s hands off my Medicare. I went to a Tea Party meeting and there were 2,700 people there. I asked them how many people were on Medicare and about 40 percent raised their hands. I asked them how many people would willingly give up Medicare. About five people raised their hands. I think three had early dementia.
Government care is not as bad as it looks. We have a socialized system, as William Frist pointed out. It’s the veterans’ care. What he didn’t point out is that it is the number one–rated health care system by the patients of any health care system in the United States of America. It is a socialized system. And who’s in it? The people who defended the United States with their lives, the Armed Forces of the United States. Not a bad system, and maybe one that more of us ought to be able to choose.
The fundamental problem with the American health care plan and the reason you’re better off getting sick — if you have to get sick — in Canada is that our system is incredibly complicated. Insurance companies who decide between your health and their profit are running the vast majority of it. Americans are forbidden from choosing systems that have worked very well elsewhere.
The fact of the matter is, we have two great countries, but this is going to turn out like the Olympic hockey game.
RUDYARD GRIFFITHS: Please rebut anything you’ve heard in your opponents’ opening statements. Senator Frist, you’re up first.
WILLIAM FRIST: A lot will be made of outcomes and where the outcomes are best. We’re not going to be able to go through each one, for cancer, for cardiac disease, length of life, infant mortality. Just be aware, because our papers — the New York Times and others — report we spend twice as much in the United States per capita than any other country and our outcomes are not as good because people don’t live as long and we have higher infant mortality, and therefore we need a single-payer system, we need universal health care.
Well, let’s have a look at that, because how long you live is not determined by how good a surgeon William Frist is or how good Toronto General Hospital is or whether you have universal health care or whether you have private insurance.
The number one factor determining how long you live is behaviour. Unfortunately, in the United States we have more homicides, and more accidents; behaviour such as smoking and obesity is more common across the board. Number two is genetics. There’s more heterogeneity there. If you factor in behaviour and if you factor in genetics, and you actually correct for those, people live longer in the United States of America than in Canada. So beware of the statistics.
ROBERT BELL: I want to come back to what Howard was talking about, that’s the issue of judging systems by the amount of care provided. How many people in this room have ever had back pain? Virtually 85 percent of the room has had back pain. How many of you have had an MRI? How many of you did anything differently based on that MRI? I don’t see any hands going up.
HOWARD DEAN: One, I see one lady. So 2 percent of the people that had MRIs will have suddenly discovered they require surgery. I remember this from my training. Most of you have degenerative back disease; you need a physiotherapist, perhaps even a chiropractor, somebody who can tell you how to look after your back. You don’t need an MRI. Thirty percent of the MRIs that are done in this province aren’t needed.
DAVID GRATZER: Maybe I’ll just focus on Dr. Bell’s argument, which is really based on two studies. They’re important studies. The first is, of course, the Johns Hopkins University report on health outcomes. I’m going to deconstruct that report.
The second is the study on medical bankruptcy in the United States. David U. Himmelstein is one of the authors of the study, and he is somebody who publishes prolifically. I think when there is a suggestion of medical bankruptcies in the United States being so dramatic, it’s worth a look.
Himmelstein gets the big publications, but doesn’t withstand the great scrutiny so well. And as you know, the New England Journal of Medicine published a paper deconstructing his study. Amongst other problems with it, medical bankruptcy was declared by Himmelstein as anyone carrying a medical debt of over a thousand dollars at the time of declaring bankruptcy.
It’s an absurd standard, and, in fact, one discovers that if you look at straight comparison between Canada and the United States, there are actually more bankruptcies in Canada than there are in the United States. The Department of Commerce statistics are 0.2 percent in the United States in 2006, 0.27 percent in 2007 versus 0.3 percent and 0.3 percent in Canada. Medical bankruptcies exist in the United States, and too often they exist here too.
HOWARD DEAN: I’m going to tell a quick story. I’m not going to do a lot of rebutting here; I think Robert Bell did a nice job of that. I had the good fortune of interviewing a young lady who actually is here at one of the Toronto hospitals — she’s an American, she trained in the United States, she’s moved up here.
Here’s what she said: “Medicine is a lot more fun to practise here. You spend a lot less time doing paperwork.” She said she spends three hours a day less doing paperwork here than she did doing paperwork in the United States.
She also told me the following story. When she was practising in Boston she admitted a young child who had the possibility of a birth injury from the obstetrics people. She was upbraided by her supervisor — she’s a pediatric neonatologist — because she hadn’t asked for an ultrasound of the head. She said, “Why ask for that, it’s not necessary.” They said because if you get sued you don’t want to spend your time in court. We’ll make the obstetrics people spend their time in court.
The truth is that most of the doctors I’ve talked to — at least the primary care people — would rather practise in Canada than they would in the United States. And the question is, do you want to be in a country where people are happier practising? I would say yes, because if they are they’re probably doing better for you.
RUDYARD GRIFFITHS: Let’s get into some specific questions and let’s start with David Gratzer. In Canada we’re spending 11 percent per capita GDP, versus 17 percent in the U.S., and not only are we living longer in Canada but we’re living for more years free of chronic disease. So isn’t that a hands-down argument for the single-payer system?
DAVID GRATZER: You haven’t persuaded me. First of all, Americans undoubtedly spend more on health care than we do. But one has to take these things with a grain of salt. When you make a direct GDP comparison, one doesn’t take into account, for instance, the medical legal environment one would have in the United States, and the fact that so much of medicine is practised as defensive medicine.
One also needs to bear in mind how much research and development is done in the United States. I’ll bet if you look at a cancer centre like MD Anderson, it has a larger research and development budget than Canadian centres combined. Again, that’s not to suggest that Canada doesn’t have points of extraordinary excellence here, but if you’re talking about a pharmaceutical drug being researched for a breakthrough in cancer, odds are it is in the United States. If you’re talking about research being done on schizophrenia, odds are it is in the United States. Most of the breakthroughs in medicine are taking place in the United States. They’re doing the world’s research and development, so some of that is unfair because it speaks to legal issues rather than the health care system. I’m not persuaded that simply because they spend more they’re wasteful. A lot of that money goes to good causes.
What about life expectancy? Senator Frist brought up a very good point. Let’s be totally frank about it: Canadians are a little bit dull compared to our American counterparts. We tend to shoot up less than Americans. We tend to shoot each other less than Americans. And I’ll be very polite to my American colleagues on this panel. How do we say this? When we go to McDonald’s we tend not to supersize the way Americans do. The obesity rate is about 30 percent in the United States. It’s unacceptably high. In Canada it’s only 20 percent.
r /> Now look, there are some really smart people, much smarter than me. Dr. Robert Ohsfeldt and Dr. John Schneider, both social scientists, did the following: they looked at life expectancy across the Western world, and they noticed that Americans are more likely to die in car accidents. That has nothing to do with the health care system. When you do a comparison of life expectancies you discover that life expectancy is longer in the United States than in any other country.
Here’s the point: life expectancy is a very crude statistic. That’s why I don’t use it. That’s why I look at disease outcomes. That’s why I think they are a better standard.
HOWARD DEAN: I think there is a lot of selective use of information here and so, even though I don’t happen to agree with what David said about life expectancy, let’s just assume that he may be right. That may be true of the end of life, but it certainly isn’t true of the beginning of life.
The U.S. has a much higher infant mortality rate than you have in Canada. Maybe you’d rather get sick in the United States, but I would think you’d much rather that if your children got sick — God forbid — it would be in Canada.
WILLIAM FRIST: It’s important to recognize what David said: these very gross global measures don’t capture universal care versus non-universal care, or any type of health insurance, or even type of facility itself.
Once again, if you compare the cost of socio-economic conditions such as people living in poverty, drug use, and abusive drug use, and if you correct for low birth weight from Canada to the United States, the United States skyrockets with a much lower infant mortality rate than in Canada. Once you correct for the other variables which have nothing to do with universal versus non-universal, or single-payer or pluralistic system, the numbers are different. So be careful.
HOWARD DEAN: Essentially the argument you’re making is that we should prefer our health care in the United States, but then we should live like Canadians. This is nonsense. The fact that this country is deeply committed to the idea that every person ought to have universal health care has something to do with the mortality rates at both ends of life.
ROBERT BELL: Let me just jump back to what David suggested, and that is that the high cost of health care in the U.S. is related to innovation. Well, it goes back a long way, but you will remember when insulin was first used on a patient. You’ll remember that stem cells were discovered by Dr. James Till and Dr. Ernest McCulloch at the Ontario Cancer Institute, leading to hundreds of thousands of people around the world having life-saving bone marrow transplants for leukemia.
I mentioned the fact that the first single and double lung transplant operations were done at Toronto General Hospital. I’ll also mention that advances for gene therapy in doubling the number of lungs available for transplant have been made by the same team in the last year and are now being used in Pittsburgh, Birmingham, and around the world.
David, America is a wonderful and innovative place full of wonderful scientists, but so is Canada.
RUDYARD GRIFFITHS: Let’s move on to innovation. The question for you, David and William, is that when you look at the cost of health care in both Canada and the United States, technology is right up there. Is technology the Achilles heel of the American system?
WILLIAM FRIST: Let me start, because this is worth spending time on. We’ve just heard five good anecdotes. But in 2001 a survey was done of great medical advances. And it showed that in the last three decades two thirds of those medical advances came out of the United States of America. One third came out of Europe. I’m not sure if Canada had any advancements or not.
In pharmaceutical development, twenty-five breakthrough drugs — these are the drugs that are going to be used by Canadians, not paid for by you, paid for by the American taxpayers to your benefit — were discovered in the United States of America or by scientists who came to America because of our robust, innovative research system.
In part, the U.S. spends more for health care because we know the benefits. Canada does a pretty good job in adopting some of the technologies, even though it’s amazing to me to hear that CT scans and MRI scans are not important. It was also amazing to hear my driver — coming in yesterday from the airport — telling me anecdotally how long he has to wait for a CT scan for a headache that’s the worst he’s ever had.
It’s amazing to me that we’re arguing that less technology, innovation, and health care are to your benefit. That’s not the case in America.
ROBERT BELL: Senator, I would suggest that technology is not innovation. Innovation is technology applied to cost-effective health improvement. There can be new machines invented every day. A great example is PET scanning. PET scanning was not approved in Ontario until very recently because the studies done in Ontario demonstrated diseases where PET scanning made a difference.
WILLIAM FRIST: If they are so bad, why are you putting one in your hospital?
ROBERT BELL: We’ve got three, because we treat a lot of those diseases —
WILLIAM FRIST: And you want more!
ROBERT BELL: You’re doggone right. But what I’m saying is that the adoption of best evidence practice to actually define where new pharmaceuticals and new technology — diagnostic or therapeutic — make a cost-effective difference to outcomes is the true thing that improves the health care system. Otherwise it’s seduction by the companies developing new technology, seduction to physicians that simply want to provide new toys to play with in diagnosing their patients. And unless they can demonstrate that there is an improvement in their patients —
WILLIAM FRIST: Why do you have, or are putting twelve CT scans in your one facility? You’re saying this is bad, so why are you doing it? Why did you show me — and it was impressive — what you’ve done there with the most technologically advanced system in the world, if technology is so bad? You don’t get your money from government and you don’t get it from the private sector. You get it from philanthropy.
In America the taxpayers pay for developments by paying more for their health care. It’s important for people to understand that innovation, technology, and research and cures for Alzheimer’s and cures for HIV someday are going to come from the United States of America. They aren’t going to come from Canada or from Europe. They’re going to come from America, in part because we pay more.
HOWARD DEAN: I think this is a great argument, but the fact of the matter is that it argues why the U.S. should be in the Canadian system. The U.S. is going to pay for all of this innovation, and that makes for a hell of a big discount for Canadians.
WILLIAM FRIST: I agree.
RUDYARD GRIFFITHS: David, are we in Canada a nation of free riders or are we being smart?
DAVID GRATZER: Look, being a free rider is great as long as you get the goods right up front. Being invited to your aunt’s for Thanksgiving is good if you get to eat at the dinner table. It’s no good if you have to wait for cold turkey for breakfast the next morning.
And I’m afraid, Dr. Bell, I’m going to have to agree to disagree with you here. Of course what we want is cost-effective medicine, but in Ontario and across Canada what we have is a system that is technologically phobic in part because we are private investment-phobic. We’ll hesitate, we’ll study, and our bureaucrats will stall. It’s part of their way of rationing the supply of health care.
New is not necessarily better, but new can be critically better. Look at the medical revolutions of the last sixty years — and when we talk about modern medicine we’re not talking about the last six thousand years or the last six hundred years. We’re really talking about the last sixty years. What we’ve done — changing childhood leukemia from a death sentence to an eminently treatable condition, eliminating polio, turning depression into an eminently treatable condition — are, for the most part, things that have to do with new drugs and new technologies.
PET scanners are a great example. You and I both know that in treating specific cancers they are critical to our understanding, and that’s why finally our government agr
eed to fund this new technology. But what happened to the people who needed that technology in 2004, in 2005, 2006, or in 2007? They were told, “Tough luck,” and some of them went to the United States.
ROBERT BELL: David, let me ask you a question. What is the most innovative therapy being investigated today for chronic refractory depression? It is neuro-stimulation.
DAVID GRATZER: I knew you were going to say that because it comes from your hospital. I watch 60 Minutes too, and you guys do great product placement. I’m not actually sure that I agree with you, though. I’m a psychiatrist, I’m not a surgeon. But you can’t cut and stimulate —
ROBERT BELL: Innovative research, it happens in Canada.
RUDYARD GRIFFITHS: Let’s shift to something that we discuss a lot in Canada, and that’s wait times. Robert, let me start with you.
The Ontario Health Quality Council came out last week with a report saying that only 53 percent of urgent cancer surgeries are being performed within the recommended time, some 750,000 Ontarians do not have a GP, nine out of ten people in Ontario say they are waiting too long to see a doctor. In a single-payer system, are these kinds of statistics permanent structural features?
ROBERT BELL: Absolutely not. There’s a change that’s occurred across the Canadian health system that is probably the most significant in Ontario, where there is a concept of measuring outcomes, measuring access to care, looking at the root causes of the problem, and making targeted investments. What we call in Ontario “pay-for-results.”
Four years ago wait times in Ontario emergency hospital departments were terrible. I’m going to tell you later what they are today, thanks to the Ontario Wait Time Strategy. Alan Hudson, the lead within the Ontario Ministry of Health and Long-Term Care on Access to Services and Wait Times, is the most significant Canadian since Tommy Douglas in terms of creating a sustainable health system because he’s shown us that you have to do root cause analyses, and you have to make targeted investments. You can’t just throw money at the problem. For example: you have to improve the processes of care that allow the elderly not to stay in acute care hospitals for longer than they need to, but rather achieve some kind of community care for them which also frees up the system.
The Munk Debates Page 20