It is sad but often true that some in public life choose to focus on and exaggerate differences between Canada and the United States as opposed to areas of common challenge and opportunity. In no area is this more apparent or illogical than in the portrayal of our two health care systems. The simplistic view, often advanced in Canada, is that Canadians have an exemplary system that serves everyone according to medical need, not financial ability. In Canada, everyone is covered. In contrast, Americans - this same view holds - have a system that is great for the rich but inaccessible to the poor, allowing for as many as 30 to 40 million Americans to remain uninsured.
The truth is that we in Canada have an excellent health care system that has been successful in most respects, but is today seriously overtaxed by a triaged and inflexible hospital-based model, creating serious shortages of high-end diagnostic equipment, qualified personnel and available beds. This difficult situation has been exacerbated in recent years by cuts in the rate of health care spending. The fiscal predicament in which provincial and federal governments found themselves during the early 1990s dramatically reduced Canadian governments' capacity to sustain the level of increased funding upon which the functioning of the health care system had been based. As a result, rather than face the waiting lists in Canadian hospitals, many wealthier Canadians simply go to the Mayo or Cleveland Clinics to meet their health care needs while less wealthy Canadians join the queue and are triaged based on urgency. Waiting lists for elective procedures and cancer treatment have become unacceptably long. The single-payer, state-funded model may be popular, but it - along with the Canada Health Act - has proven to be a formidable barrier to change. And, these days, the single payer systems in our provinces are sending many patients - every day - to adjacent US treatment centres - as a way of managing the pressures here!
Certainly, we cannot ignore the fact that, at any one time, 30 million Americans may lack proper health insurance and therefore have limited access to the system. But it would be disingenuous to suggest that the Canadian system is not plagued by similar difficulties. In many cases, excessive waiting lists or queuing also limit access to care. To pretend otherwise is to engage in the kind of Ostrich-like behaviour our health care system cannot sustain.
In fact, if a Martian were dispatched to do a review of health care systems in North America, he or she would be more likely to report back that the Canadian and American systems have some glaring similarities. In both systems, the levels of anxiety on the part of doctors and patients run high. In the US, this anxiety is the result of some HMOs' attempts to discourage utilisation and control costs and choices. In Canada, the anxiety is a result of ever-growing waiting lists, themselves at least in part the product of single-payer government health plans that seek to discourage utilisation and control costs. On a macro level, the differences in the funding formulae of the two systems tend to be emphasised. But for the individual consumer of health care services, the result is often quite similar: dealing with the health care system, in whichever country, is all too often a needlessly complex and frustrating experience, no matter the source of funding.
If there is one weakness that typifies the post-war response of governments in Canada, the United States, and Western Europe to legitimate social policy challenges, it has been the tendency to seek large, systemic, solutions. In some cases, such as the US social security system or Canada's Old Age Security and Canada Pension Plan, these may very well have been the right points of departure at the time.
But in an area as complex and intimate as the relationship between an individual and his or her physician, it is not at all clear that heavy systemic responses - by either government or private sector actors - make any real sense.
In fact, if we can draw any conclusion at all from our experience thus far, it is that the variations between rural and urban North America, the differing needs of various demographic groups, the mix of therapies now available, as well as the range of choices and costs relating to models of care, diagnosis, treatment and preventive activity, do not argue for the constraints of a single, heavy-handed government or HMO dominated system. Rather, our experience suggests that we ought to embrace models of health care delivery that accommodate and encourage diversity, not ones that suppress it. There is no relationship more personal than that between a doctor and his or her client. Health care models should respect rather than frustrate that reality.
In a blueprint for Canadian health care reform published by the IRPP in 1998, entitled "Who Is the Master?" the authors called for the creation of a series of "Targeted Medical Agencies" local or regional organizations with flexibility, accountability, and much more intimate community, patient and provider relationships.
Rather than the rigid fee for service system for physicians and the global funding scheme for hospitals - the option of per patient capitation and locally negotiated service purchase from hospitals - by the local TMA is suggested. This would encourage the efficient provider while reducing the pressures sometimes produced from "piecework" medicine.
The co-authors, a former Quebec Minister of Health, Claude Forget and my predecessor at the Institute, Monique Jerome Forget, herself a former Assistant Deputy Minister of Health at the federal level, engaged the issue of Health Care reform by pointing out that Pope John Paul II rehabilitated Galileo in November of 1992, some 350 years after he was condemned for agreeing with Copernicus that the earth was not at the centre of the universe. Some myths die hard.
A fitting preamble for a careful look at health care.
We should have the courage to ask some of the tough questions that established interests on both sides of the border seem unwilling to address:
As a Canadian, I retain a fundamental belief that everyone in society has a right to basic medical care without regard to issues of affordability. And, to be fair to the American system, it would simply be inaccurate to suggest that, with all the hospitals that treat the uninsured and with all the physicians who give free clinic time, there was not a similar sentiment among a majority of Americans.
The goals of universal access, excellence, improved outcomes and more flexibility are real in Canada and attainable in the US. But they require not the certainty of the ideologue but the open-mindedness and creativity of a genuine search for new models. I believe we need to be adaptable as to means and approaches. Rigidity in defence of established approaches is no virtue. Creativity in search of better ways of achieving appropriate policy outcomes is no vice.
In fact, if we have learned anything during this period of enhanced mobility for both capital and people, and the intense use of information technology to reduce the limits of space and time, it is that the old instruments of public policy that were conceived in the 18th or 19th centuries, or even in the 40's, 50's and 60's of the 20th, may not be the best instruments for the age in which we now find ourselves.
This does not mean that the goals of public policy are or were wrong. It may simply mean that the instruments by which we achieve them have to change.
It is precisely the wrong time to retreat behind national borders to look for new answers. It is precisely the right time for Canadians and Americans to pool expertise and experience to shape a constructive set of new options that each country could consider within the context of its own political context and culture. While our institutions, approaches and visions for the future of health care may well differ, we should not be afraid to do research and fact finding together.
A Joint Canada-US Commission of Inquiry into the Health Care Requirements of both Societies could produce a gathering of expertise and intellect, experience and policy breadth unparalleled in the history of both our countries. Each sovereign country would make its own decisions on the findings - but we would benefit by searching out options together.
If there were ever a time for inspired peacetime collaboration, it is now. If there were ever a compelling issue on which to collaborate, it is health care.
Led by distinguished policy leaders from both countries in equal numbers, and staffed by experts in clinical, financial, preventative, epidemiological, and medical education areas, such a Commission could pave the way for a new millennium of courageous policy and organizational choices for each country. If appointed in 1999 or 2000, this Commission could report to both the American and Canadian federal governments before the middle of the next term - to be elected in the year 2000 in the US, and in 2001 here in Canada.
Inquiring with both vision and foresight, we could take a collaborative look at:
At a time when many Canadian provinces send their patients to US centres for treatment because it is cheaper than building increased capacity here in Canada, and at a time when more and more Americans are choosing Canada for certain elective procedures because of cost, both systems would be terribly naive to believe that they are hermetically sealed from one another.
They clearly are not. And it strikes me that we would be well served to move beyond the rhetoric of those in Canada who portray our system as more pure or altruistic, and beyond that of those in the US who portray the American system as more patient sensitive and technologically advanced. We have a tremendous amount to learn from each other and, more importantly, we can learn a great deal more and achieve great things if we work together.
Getting health care right is about as vital a concern for Americans and Canadians as one could imagine. It is high time political leadership in all parties on both sides of the border embraced and engaged in a genuine effort to make the progress on this issue that Americans and Canadians deserve.