The Munk Debates

by Rudyard Griffiths

  There’s no question in the Canadian system that innovation is crucial to sustainability. My point of view, having talked to my colleagues who run American hospitals, is that our ability to innovate is far greater because we only have to deal with one insurance company. I don’t know how many times I’ve heard an American CEO say something like, “We’d be able to send all those patients out to community care, except the insurance company won’t provide us with co-pays and …” I didn’t even know what all the terms were when they were talking about insurance companies.

  I think our ability here to talk to the people — the democratically elected representatives that represent the patients getting service — is not such a bad thing.

  RUDYARD GRIFFITHS: Howard, this question is for you. Why do you not take advantage of market forces in terms of allowing for private medicine? Why is the market the big bugaboo for supporters of a single-payer system?

  HOWARD DEAN: The market doesn’t work in health care. Let me explain why. If a Ford dealer comes into town and there’s already another one there, then generally there is going to be some price competition. But if somebody builds a new cardiac catheterization lab, it just gets used a lot more and it costs the system a lot more money.

  Let’s suppose you’re my patient. If I’m a car salesman and you’re coming to see me to buy a car, you decide what you want to buy and how much you can afford or if you can afford something at all. But if you come to see me as a patient, I tell you what you are going to buy, I tell you how much it is going to cost, and we send the bill to a third party. There is no relationship of supply and demand in the transaction between doctors and patients.

  Secondly, this is a commodity that is essential for life. So even if we were to ration it somehow by price, which is sort of what we do informally, there would be a huge moral component to doing that because then everybody who couldn’t afford it would get cut off without health care. Market capitalism doesn’t work in health care.

  Does that mean it never works? No. There are some areas where it makes some sense. There are little snippets here and there, but this system will never be a real market system. It’s why we have this very hybrid way of doing things in America. Ours evolved differently than yours did. I think yours is much more ordered.

  In Medicare, 4 percent of money that is given into the system gets spent on administration. The average insurance company pays between 14 percent and 28 percent. There’s a ton of money that is spent on bureaucracy. And it’s one of the reasons the American system is so much more expensive than yours.

  But don’t ever let anybody tell you that market capitalism can work in health care. It cannot and it never will and it shouldn’t.

  WILLIAM FRIST: I think this is an important point because one of the objectives of this debate is to make clear the contrast between the different systems. Markets do work in health care. We need to work towards making them work better in health care, however.

  There are a lot of examples that I can give. As a policy example, in 2003, prescription drugs were not a part of our seniors’ Medicare program. For 42 million seniors, prescription drugs are probably the most powerful tool in our armamentarium to fight disease. Prescription drugs had been excluded from the Medicare program and in 2003 we put them in, and 42 million people, as part of their basic package, had affordable access to prescription drugs.

  We did it because we believe in markets. We did it in such a way that if you have 42 million people, you would have 5 million people competing against 3 million people, competing against 2 million people versus 4 million people, with bargaining, negotiating, and competition on the price of drugs.

  That was the first time it had ever been done in our single-payer system. But we are beginning to open up that system to the markets, and with that the cost of prescription drugs — one of the big drivers in health care costs today — has come down 20 percent each year, more than predicted. It was the result of prudent decision-making and trusting individuals to make those decisions rather than a few bureaucrats in Washington, D.C.

  For markets to work it goes back to building on what Howard said. You need to have a prudent shopper and you need to have a price and you need to have somebody who is selling something or providing something. And you have to have transparency, full accountability, and understanding of what you are actually buying.

  In health care, we, in the U.S. and Canada, have underinvested in information technology. You need to know what’s out there. So you ask, how much is that CT scan? How much is that MRI machine? And what are the benefits? We as consumers should decide, not bureaucrats, not politicians in Washington, D.C. And that’s a fundamental difference.

  In America, we want to be in control and make decisions when it comes to our child with leukemia. We don’t want to be told that technology is not the answer. We want the best and we want the transparency to be able to determine that.

  And it’s not going to be what we heard from Governor Dean during this debate, that waiting times are okay. You would not feel that way if you had a child in that situation. So I believe that markets do work.

  One other thing I’d like to mention is that the examples of private sector investment in research, in creativity, and in the new drugs and new devices — and in the CAT scans and CT scans we looked at — are coming predominantly from our private sector. David mentioned that one hospital in the U.S. has a research budget bigger than your entire country. And I know there are ways to explain that, but the U.S. spends 123 billion dollars every year to give you advances, to give you the cures, to give you the new tests, and 60 percent of that comes from the private sector. Forty percent comes from our government.

  If you open a bit to the private sector and to competition in this country, if you don’t say “no” reflexively, those are the sorts of advantages that you will see across Canada.

  RUDYARD GRIFFITHS: This final question is for Robert and David because it’s a Canadian question. Do user fees — such as the twenty-five-dollar user fee proposed by the Government of Quebec— help limit waste, abuse, and fraud?

  DAVID GRATZER: As a physician and psychiatrist, I’m very conscious about the user fee issue because many of the patients I treat are people who have severe mental illness, for instance, homeless schizophrenics. Obviously you’d never want a user fee for that group. But I think that there are many groups where it would be applicable.

  I think in Canada we’ve been just too unambitious in reaching out to the rest of the world for ideas. In Sweden they have user fees. Many countries have some sort of cost-sharing mechanism. The trouble is that we’re not studying our system and saying, where can we find new ideas? We’re studying our system through the prism of nationalism. So I like user fees for some people. I like full cost for other people, by the way.

  When Conrad Black is finished his jail term, or perhaps if he wins his appeal, he’ll come back to Canada and he’ll be in his mid-sixties. Prescription drugs will be completely free to him at the point of use. He’ll leave his house on the Bridle Path, he’ll go to the pharmacy, and he won’t pay anything. You’ll pay for it. That is an absurdity.

  We need to have a mature discussion in Canada about what we’re going to cover and how and for whom. I also believe we should be means testing more than prescription drugs.

  ROBERT BELL: I don’t like user fees for the reasons that David mentioned. Some of the people that need care most are unable to pay user fees, so you start giving in to this terrible health-equity situation. But more important than that, user fees are actually a cop-out. They take our feet away from the fire. If you’ve got a system that you’re worried about in terms of sustainability, why are you looking at bringing more money into it by charging people for access? Why don’t you talk about reducing costs and improving quality?

  I think user fees are a reflex answer. I don’t think they are socially equitable, nor do I think they’ll stimulate the kind of innovation that we need.

  DAVID GRATZER: That’s the prob
lem in Canada. Someone comes up with a perfectly reasonable idea and we immediately shoot it down. If Sweden, the home of social democracy and also eugenics, can embrace this, why can’t we even consider it? Sweden is a country where, if you are not feeling well, the government will not only give you short-term disability, they’ll send you to the spa for seven weeks. It is a socialist country.

  No one is suggesting that this will solve all of our problems. But if it is an idea that they can embrace in Western Europe, we ought to use it here because we’re in a real pickle. We will have more elderly people than children over the next five years, and we’ve got a system that is completely unsustainable and, frankly, not yielding good results. Everything ought to be on the table.

  HOWARD DEAN: We debate this internally in the U.S. all the time and I don’t have a big problem with user fees, although I think Robert is right, it’s a bit of a bureaucratic nightmare. The problem with user fees is that it doesn’t do the job. The huge cost increases in the United States are not because of how many times you see your family doctor or even how many prescriptions you get. The enormous cost increases are from how many CT scans, MRIs, and cardiac bypasses we do, and there’s not a user fee that’s going to deter that.

  RUDYARD GRIFFITHS: Well, the time has come for our debaters’ closing arguments. I want to call on our debaters in the reverse order of their opening statements, so Governor Dean, you are up first.

  HOWARD DEAN: First, let me make this point. I actually think that it is likely — and I saw a poll in the Globe and Mail that said that 64 percent of Canadians think this is true — that our two systems are going to show some convergence over the next couple of decades. In fact, Canada may adopt user fees, and the U.S. may adopt a larger form of a single-payer system. So there will be some convergence, but here’s what I’d like you to keep in mind as you decide that it is much better to get sick in Canada if you have to get sick.

  These are two great countries. At the top end, our medical systems are very good. It’s true that we pay for a lot of innovation, but it comes across the border, so it works fine from the point of view of what happens if you get sick in Canada.

  The question is, what kind of system do you want to live in? Do you want to live in a system that covers every single citizen of your country, or do you want to live in a system where two thirds of people can get what they need and the others can’t? Do you want to live in a system where 18 percent of the gross national product is spent on health care, or do you want to live in a system which also has increasing health care costs — but where only 11 percent is spent on health care?

  Your universal health care system is 70 percent cheaper than our system, which isn’t universal. Yours is simple. It’s easy to understand. Everybody gets coverage. Both of our systems have a lot of problems. The argument that I would leave you with is that for whatever faults that you have in Canada, and there are plenty, you have a system which is coherent, you have a system which is universal, and you have a system which is morally justifiable. We have none of those.

  If I get sick in the United States, I think I’m going to get pretty good health care. And if you get sick in Canada, you have pretty good health care. The question you have to decide is whether you are going to be one of the 35 percent that can’t afford it in the United States or whether you’re going to be guaranteed of having that health care. And what you are essentially buying in this country is the notion that no matter what happens to you, your children will not be burdened because of this extraordinary need that all of us have for decent health care.

  Most of us will never need to use that much health care in our lifetimes, but we don’t know which of us will need that care. In Canada you’ve done something about that. We have yet to do it.

  DAVID GRATZER: Born and raised in Canada, I used to support our system. I thought it was better than the system in the U.S. I believed some of the same arguments you’ve heard during this debate from our opponents about the Canadian system having better outcomes and at a lower cost. I re-examined things working in hospital rooms and emergency wards. I met people who were waiting for treatment in pain and in fear. It made me rethink everything I thought was important about our health care system.

  I did what scientists are supposed to do. I looked for evidence of what was wrong. I discovered our problems were consistent across the system and across the nation. A decade and a half later we are still putting national pride ahead of patient needs. Yes, there are advantages to the Canadian system. Everyday drugs are cheaper. The paperwork is easier. Doctors can never charge you if you show up to the emergency department with a runny nose.

  It’s the best health care system in the world as long as you don’t get very sick. But when you do, you discover a different system. As if the anxiety and pain of cancer weren’t already enough, in a recent survey the Canadian Breast Cancer Network found that eight in ten breast cancer survivors suffered serious financial consequences from their treatment. One in five incurred significant debt in Canada. How could that happen in a country where health care is supposed to be free?

  The reason is, we put politics first. The flu shots are free but the PET scans are capped. And the cancer drugs may not even be covered, depending on what a handful of bureaucrats decide. This debate is more complicated than a simple resolution. Tommy Douglas said that we should measure the success of a health care system as a system that keeps people healthy, not just a system that patches them up.

  It is true that in both countries we need to improve wellness. But in terms of patching people up when they are sick, which is what the resolution is ultimately about, their system is superior. Study after study says the same thing. Their five-year cancer outcomes are better than ours; the same thing with heart attack and stroke and spinal injuries. And, yes, transplants, too.

  Dr. Bell, you had one study, from Johns Hopkins University — an impressive school — but I’ve taken into account studies from The Lancet Oncology and a slew of other journals. You know why the U.S. has better outcomes? Because in the United States they spend more and they’re more innovative. In Canada we tend to judge the system by a political standard. But I believe we should measure Canadian health care based on a medical standard.

  Too often we fail to deliver the care people need in the medically recommended time. Let me be clear again and say this: the American system is not perfect. We can learn much from that system, but we can learn much from Europe and Asia as well. But the American system is more advanced, delivers timelier care, and if you are ill it is more likely to heal you.

  Go back to the resolution. It’s not which system is more nationalistically satisfying or which system makes you feel more emotionally well. It is, where would you rather get sick? The answer must be where the outcomes are better — in the United States.

  ROBERT BELL: There is a marketplace that determines health care outcomes in Ontario. It’s a social marketplace that provides information. You can go find any procedure on the Ontario Wait Times Strategy web site, you can find waiting times for procedures provided across this province in any hospital.

  Here’s what you’ll find: about 3.7 million people are treated and sent home from our emergency departments every year. Nine out of ten of those people have left the hospital within 4.2 hours after they arrived. These figures have improved dramatically over the past three years.

  If you’re having a heart attack — you can’t get sicker than that, referring to David’s comment — 90 percent of Toronto patients have their blocked arteries dilated and stented within ninety minutes, a time that saves heart muscle from destruction. The average breast cancer patient in Ontario has completed all tests and had surgery within three weeks, according to the web site. And nine out of ten patients have completed their initial stages of treatment, diagnosis, and surgery within five weeks. As for hip replacement in our hospital, 90 percent of people receive their treatment within three months. Across the province, nine out of ten patients complete the surgery within five m
onths. All the data is there for you to see on the web site — heart treatments, cancer treatments, surgery for all types of disease.

  And if you don’t like the hospital you have been referred to, you can always look for a different hospital, providing better access to care. Each hospital has provided all their data, and performance has improved dramatically over the last four years.

  Remember, as the Governor mentioned, the most dangerous beast in the animal kingdom is a surgeon without a waiting list. If you see a surgeon and they book your surgery for next week — as many of our colleagues south of the border do — then you need to ask yourself: do I need the surgery or does the surgeon need to fill their OR list?

  If you’re wealthy and you want to pay a premium for immediate access to care, as Danny Williams did, you can get it more readily in America than you can in Canada. However, you are also much more likely to get economically driven unnecessary surgery or treatment in the United States, and with the advent of pay-for-performance, our wait times are shrinking.

  There is no question that we need to improve our system. With public accountability through publishing data on web sites, we are now developing a true system where inputs and outputs, including quality, can be measured and improved at a fraction of what you’d pay in America.

  Ladies and gentlemen, we are all engaged in a creative, entrepreneurial exercise, designing publicly funded health care which will be cost-effective and high quality for our children and grandchildren. We need to keep our nerve and keep demanding accountability for money and quality, not asking whether or not we have the right system.

  WILLIAM FRIST: If your daughter has cancer, you want the best for her and you want it now. You don’t want to have decisions made that ultimately reflect back to decisions that were made by a bureaucrat, by a politician, by somebody at the top. And you don’t want access to a specialist, the one who has spent his or her lifetime studying leukemia, that cancer that your daughter has, limited by rationing that occurs somewhere far away.