The Munk Debates

by Rudyard Griffiths

  We are involved in a noble experiment — a Canadian publicly funded universal health system is a system that’s defined by cost-effectiveness. We don’t throw money at problems. We make targeted investments. That’s a new approach. And I think it’s the thing that is going to make this system sustainable for our children and our grandchildren.

  RUDYARD GRIFFITHS: William, statistics show that you’ve got shorter wait times in the U.S., but again the equity in terms of access to the system is a major issue. If you were sitting here unaware of your place in the world, wouldn’t you prefer the Canadian system?

  WILLIAM FRIST: I disagree with the assumption or the premise that Canadians have better access to care. I spent twenty years in medicine doing things like heart transplants, which were very expensive at the time, and they were not covered here. Out of 150 heart transplants I’ve done, 40 percent were on individuals living under the poverty level.

  I say that because the impression is always that the uninsured in the United States don’t get care. And they do get care. Being insured matters, and that’s why the government has addressed that in the new legislation, which extends coverage to 32 million more people.

  There are 30 million hardcore uninsured. So the equity issue is a real issue. But for the overwhelming majority of 250 million people, access to care is good, and it’s not from a single spigot, which is what occurs when somebody at the top gives the hospital a budget and that budget is the criteria they’re using throughout the year.

  In America it is not done that way. There are various spigots. There is the private insurance spigot. There is the Medicare spigot coming from government. There’s the Medicaid spigot which comes from individual states — about 50 percent of it is state resources and 50 percent is federal resources. So the flow of resources gives, in a pluralistic system, flexibility of access and of quality.

  The quality of the outcomes always ends up being sort of a wash. The access issue is important, and in the United States the uninsured — and, yes, having insurance matters — do get care. Where do they get care? Through 6,000 community health centres that are predominantly for the uninsured, and through emergency rooms. Once you hit that emergency room door — and, yes, you should be seeing primary care, and we have a primary care shortage in the U.S., just like Canada — you get equal care, regardless of where you might be on the socio-economic scale.

  This was legislated in the 1990s. It may not be the ideal way to do it, it’s inefficient, but the uninsured do get care in the United States.

  RUDYARD GRIFFITHS: Howard, are you getting the best of both worlds? You are getting good access as well as quicker access.

  HOWARD DEAN: Well, let me answer a question that you raised earlier. You said, is there something endemic about the single-payer system where you have to have wait times? The answer is no. We have a single-payer system for everybody over sixty-five in our country, and there are essentially no more wait times than there are for anybody else. I do believe not all the wait times, but a great many of the wait times, are probably something that is a good idea. The alternative is that you get whatever you want when you want it, and you look at those ads on television and you can go and give the doctor a list of all the medicines you expect to have prescribed to you within four minutes. And that is all the time you get to see the doctor in the United States, by the way. How long is your average office visit in Canada? It is six minutes in the United States. I’m not kidding, that’s what happens when you have a private insurance market.

  Let me briefly talk about unnecessary procedures. It is true that eventually most people who are uninsured get care. How would you like to get your primary care in an emergency room? Do you know the percentage of American medical graduates in 2008 that went into primary care? The answer: 9 percent. Does that tell you something about how unpleasant it is to practise if you’re a primary care physician in the United States of America?

  In Canada it’s about 25 percent, which is still much too low. There is something about the American system which grinds out the people who are going to see you first in the medical system. Mostly I think it’s the private insurance sector that grinds them down. So I do believe that the evidence is overwhelming that the Canadian system is better, and that the U.S. needs a system where at least we can give our folks a choice between the private system and the socialized system that’s currently in place. Give us that choice and then our system will at least be what we want it to be.

  RUDYARD GRIFFITHS: I want to move on to a final topic, a question for both teams of debaters. I’m going to start with our pro debaters first. I’m coming up on my fortieth birthday, and as part of Generation X our big question is, what kind of health care system is going to be around in twenty or thirty years?

  WILLIAM FRIST: Let me comment on the American system and where we’ll be. Our recent legislation added 32 million people to the insured. Sixteen million went into the government plan for Medicaid. Medicaid pays about 60 percent of the cost of taking care of a patient. It pays hospitals about 40 percent of the true hospital costs. So if you put everybody into that, the system would clearly implode. We would have no doctors or hospitals left in thirty years.

  The other half went into the private sector through private sector exchanges and privatized plans, which gives a little bit of a feel for where the U.S. will be down the line. It will be a blended system. It will be multi-payer funded. It will give choice in terms of physician and in terms of plan — there’ll be more transparency through a 20-billion-dollar investment and the part that we put in from the Obama administration for information technology.

  Whether or not you are healthy twenty years from now, let me come back to a very important point. Your health is going to depend more on whether or not you smoke, whether or not you drive fast, whether or not you wear a seatbelt, whether you are obese, than it is going to depend on Toronto General Hospital or Massachusetts General Hospital or health care systems themselves.

  ROBERT BELL: You’re talking about that magic word “sustainability.” Is the current system sustainable? There is a bit of an urban legend out there that it can’t possibly be sustainable. How can it keep on growing? The answer is that there is no magic.

  There are three things, three big cost drivers in the publicly funded health care system: hospitals, drugs, and doctors. Hospitals are pretty much getting under control — a 1.5 percent increase this year — but it’s forcing us to find better ways to manage the 3 percent inflation that we’re facing.

  There may be pharmacists that are going to be upset if I say that the move on generic drug pricing is probably going to help us pull down costs, and my sense is that the Ontario Medical Association wants this system to be sustainable just as much as we do and they’re ready to come to the table and talk. So don’t believe that this is definitely an unsustainable system. I think there are all kinds of ideas being brought to bear right now which are going to provide us with better quality at better cost.

  DAVID GRATZER: There is a really famous American economist by the name of Herbert Stein. Stein was a brilliant man. At one point in time he was actually an adviser to the President of the United States, and he coined Stein’s Law of Economics. Stein’s law says simply: that which cannot go on forever will eventually stop.

  Okay, maybe it wasn’t so profound, but when it comes to health policy it is profound. Canada has enjoyed really good economic times. Oil was trading at 150 dollars a barrel at one point in the last few years. And health spending has risen 8 percent annualized over the last decade. We won’t have the type of investment in public health care the way we have had in the past. Difficult decisions will have to be made.

  Our population is aging. A new Statistics Canada report suggests that there will be more seniors than children some time in the next half decade. As we move forward there are certain things Canadians need to do that our politicians don’t like to talk about. One is to take health, not just health care, seriously, for the reasons that Senator Frist outlin
ed. One in five Canadians is obese. They are opening themselves up to a slew of health costs that could be avoidable.

  We need a role for the private sector in Canadian health care. The Labour government in Britain was able to contract out in a big way. In Ontario it’s scandalous that there are no private MRIs serving public patients. And the third thing we need to do is have a meaningful discussion about patient cost-sharing. Every time these things get raised we hear that it is un-Canadian because it’s an Americanization of our system. Fine, then what about a Swedification of our system? In Sweden, if you show up at the emergency department with a runny nose, you have to pay a user fee.

  I also like experiments with medical savings accounts that you see in the United States. What I’m suggesting is that we should talk about those sorts of cost pressures instead of saying that what makes us Canadian is that we’ve got a free health care system that might leave you on a wait list.

  The point of this system is not nationalism. The point of this system is to serve our patients. If Sweden has a good idea, let’s look to Sweden. If Latvia has a good idea, let’s look to Latvia. And if the United States has a good idea, that’s okay, too.

  RUDYARD GRIFFITHS: Howard, let’s get you in on this question. Is there an advantage in the American system insofar as you have crossed the Rubicon a while ago in terms of individuals paying for their health care personally? And do you think a single-payer system like we have in Canada will exist twenty or thirty years hence?

  HOWARD DEAN: There have been numerous people from a different party than I that have tried to undo Medicare, and their corpses are littered across the political scene, along with people who try to undo our social security. People love our health care system if they’re in Medicare. The grass is always greener on the other side. Let us choose, if we’re under sixty-five, to get into what people over sixty-five have. But what people over sixty-five have is essentially what every single one of you has.

  There are faults. I agree with David that it wouldn’t hurt to have co-pays. I mean there are economies of scale and some things that have to be done and incentives have to be changed. I think the pay-for-service system is a mistake for both countries. But the fact is you start with having everybody covered with health insurance. I don’t think it’s possible to know how valuable that is unless you live in a country for a while where everybody doesn’t have health insurance.

  RUDYARD GRIFFITHS: Let’s go to some audience questions. First question to Robert. Why did Danny Williams, the Premier of Newfoundland, go to the U.S. for health care rather than seek service in the province that he governs?

  ROBERT BELL: If I were the Premier of Newfoundland and I had to leave the province because the procedure wasn’t available there, it might be easier to go to South Carolina than Toronto, where the procedure is also available. I’m not positive, but that may be the case. But I don’t know exactly why he made that personal decision.

  DAVID GRATZER: We all know that the premier left to have heart surgery in the United States, but we also know that many politicians do that. And it follows a relatively simple pattern.

  First, they rail against the American system when they run for office. Then they have a lump or a bump and go to the United States for care because they have looked at the same statistics I have, and then they come back and they feel really badly and some of them give Robert some money.

  Let me be clear. I don’t begrudge the premier for going to the United States. I dislike his hypocrisy. And I also wish that he would have had the opportunity in Canada to have a public versus private option. Instead of spending those health care dollars in Miami, I wish he had had the opportunity to spend them in St. John’s.

  ROBERT BELL: Canadians have a tendency to hide some of our light under a bushel. Former U.S. Senator Paul E. Tsongas talked about his life-saving bone marrow transplant and how he got that in Massachusetts and wouldn’t have got it outside. In fact, bone marrow transplants were invented in Canada, and this is where stem cells were discovered. And yet we never really talk about that.

  We don’t brag about some treatments that Americans come here for — we have patients coming here to receive special surgeries they can’t get in the United States, performed by doctors like Tirone David. There are a lot of Americans coming here for surgery.

  DAVID GRATZER: It’s also not so relevant to the overall debate. Let me say that Dr. David is an extraordinary individual. I did part of my training under Dr. Robert B. Zipursky, who might be the world’s foremost expert in first episode psychosis. So what?

  The point is that Canadians wait for care, and as a result, while we can find exceptions, we find a system so overstretched that the Ontario government spends 164 million dollars a year taking our patients to the U.S. for treatment.

  What you find when you’re on a wait list here is that our political class opts out. It’s the hypocrisy of living in Canada that you have to listen to Danny Williams drone on about why we have such a great system, but when it’s his heart, he’s on the next plane out of here.

  I don’t dislike Premier Williams. If he wanted to buy alcohol it would be legal. If he wanted to buy tobacco it would be legal. If he wanted to go to certain parts of Toronto at night and procure the services of a lady friend, for all intents and purposes it would be legal, and I think private health care is a lot better for your health — despite what Governor Dean has suggested — than it would be to buy tobacco, alcohol, or a lady friend.

  WILLIAM FRIST: The United States of America is the number one tourist destination for advanced quality care in the world. That includes transplantation, that includes advanced cancer therapy, and that includes cardiac disease. It is the place that more people come to for advanced care.

  ROBERT BELL: David, you mentioned the number of Ontarians who go to the United States for medical care. How many Americans go to Thailand and India practising medical tourism and get care that they can’t afford and at reasonable quality in those countries?

  HOWARD DEAN: Let me just say something about Premier Williams going to the U.S. for heart surgery in South Carolina. There are foolish consumers everywhere. Unfortunately, this debate plays into a Canadian national characteristic, which is that you assume that if somebody goes to the United States it means something bad about your system. In fact, he may have just done something really stupid.

  I’m sure they have very nice care in South Carolina, but I’ll tell you one interesting statistic. This is from the New England Journal of Medicine from fifteen years ago. For-profit health care delivers much worse results than not-for-profit health care. I don’t think you have for-profit health care institutions in this country. Florida has the worst health care in America, and they have the highest percentage of for-profit institutions because they have got to make a lot of money so they do a lot of stuff.

  So all I can say is Godspeed to the Premier of Newfoundland. I’m glad he came back in one piece.

  RUDYARD GRIFFITHS: Aren’t health care systems a reflection of a society’s shared values, especially their concern for the least fortunate?

  WILLIAM FRIST: The equity issue is important, and the United States is not perfect. But a pluralistic system is a system by definition that is fluid and that gives choice, and that will alter under a single-payer system. It’s pluralism where you can innovate.

  Things aren’t going to work out if you put markets forward. And that is in part why a number of presidents, including President Obama, said, “Forget the cost of health care. We’re not going to do anything about it. Even though health care is more expensive in the U.S. than in Canada and the population is growing three times faster than inflation, we are going to bring the uninsured to the table.” For that I applaud him, but having some insurance does matter. So that’s the law of the land in America and now, but the cost issue has to be addressed.

  Dr. Dean wants to expand Medicare, which is a very popular system, a very generous system — more generous than your system in Canada — but it’s not sus
tainable. Our single-payer system is going to go bankrupt. So that doesn’t mean you sustain it, it means you improve it.

  Part of that improvement that we haven’t talked about that we need to talk about is changing health care into a more value-driven system. We need a system that is built around outcome and results per dollar coming in. And there are ways to do that. We didn’t do it in our health care bill recently, but a value-driven system versus a volume-driven system is something on which I think we can all agree.

  DAVID GRATZER: My job during this debate is not to whitewash the American system. My job here is not to suggest to you that it is a perfect system. Certainly I don’t believe that. I wrote a book a couple of years ago talking about all the problems with the American system.

  But I would suggest the following to you: we let ourselves off the hook too easily in Canada when we talk about problems in the American system. At least they’ve had a discussion about the uninsured. At least they’ve taken a step to address it. Here in Canada you’ll never pay to see a family doctor. But getting to see a family doctor isn’t so easy.

  According to the Canadian Medical Association, four million Canadians — probably more — can’t get a family doctor. There are towns here in Ontario where they hold lotteries and the people who win get to be taken in as patients by the town doctor. That’s unacceptable, as I would suggest to you the uninsured problem in the United States is unacceptable and more needs to be done. We have significant access problems in Canada, too.

  ROBERT BELL: What we’ve been engaged in is a discussion of the American and Canadian systems. We both need to be ashamed if we compare our systems to the Danish system, where every family doctor has an electronic record where patients can book their appointments online and get information from their family doctor by email as opposed to having to wait for a visit.