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Last week we discussed the United States health care system. This week we discuss Canada's. We also take some time to bust some myths about their single payer health care system. Fight about it in the comments below.

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References for a lot of the "myths" about Canada can be found here:
Aaron's series on quality is here:
Canadian wait time data is here:

John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen - Graphics


It's never been clear to me why so many people in the United States are so worried about the healthcare system in Canada. Sure, they have a single-payer system, but we sort of do too. Both their system and ours are called Medicare! The biggest difference is that theirs covers everyone, and ours only covers the elderly.

Here in the United States, single-payer healthcare is as American as apple pie if you're over 65, but a communistic tyrannical end to freedom if you're 64. Canada, however, has no such problem. They're all in for Medicare. And their system is the topic of this week's Healthcare Triage.

[intro plays]

 About the Canadian Healthcare system (0:41)

Pretty much all Canadians receive their healthcare coverage through public funding, with spending decisions made at the province level. Most healthcare is free to those who use it, with no money out of pocket. Medically necessary care is covered, including maternity care and infertility treatments. The government pays for about 70% of total healthcare spending. The other 30% is private spending. Most of that is for drugs, dentists, and optometry, which aren't covered by the government program. Most Canadians buy supplemental private insurance through their jobs to cover the cost of things not covered by their Medicare. 

Most hospitals are publicly funded, and they're required to operate under a fixed budget. This is one of the ways that Canada controls its healthcare spending. But most family physicians are private, and most actually operate on a fee-for-service basis. This is what makes them a single-payer system but not a socialized medicine system. Public spending but private delivery system. And doctors do pretty well there; in 2012, the average doctor's income before taxes was about 225,000 Canadian dollars. Generalists make a bit less. Specialists make a bit more. Canada negotiates at a federal level for its drugs; this is another way that it controls spending. 

 Waiting Times (1:48)

Canada has somewhat of a reputation for wait times. There are days when it feels like everyone I talk to knows someone who's just been screwed by the Canadian healthcare system. Data, however, don't support this assertion. Canada's quite good about being transparent about its wait times. You, and I mean any of you, can go to official websites and see the average wait times for all kinds of things, just by using the internet. Go ahead, give it a try! We put a link in the video info below. By the way, I challenge you to try to find out this kind of information in the United States. Most people just assume the US is better, when it's often not.

Moreover, most of the wait times in Canada are for things that are elective. They may be longer than some would like, but they're not in any way life-threatening. 

But why are there wait times at all? Because limiting supply is cost-effective. Canada spends remarkably little on healthcare, which leaves the country lots of money to spend on other things. They also focus more on outcomes that matter to health, and less on process measures, like "how fast can you get an optional MRI" than other countries do. And if Canadians really cared en masse about fixing these things, they would do so. I encourage you to go read my series on quality again; link in the video info section. See how Canada really compares to other countries. You might be surprised. 

 Myth 1 about the Canadian Healthcare System (2:59)

While I have your attention though, let's go over some myths about the Canadian healthcare system.

One: Doctors in Canada are flocking to the United States to practice. Every time I talk about healthcare policy with physicians, one inevitably tells me the doctor he or she knows who ran away from Canada to practice in the United States. Evidently there's a general perception that practicing in the United States is much more satisfying than countries such as Canada. 

Survey after survey shows us that's not the case. Docs in Canada like working there much more than doctors like working here. There are data on immigration. The Canadian Institute for Health Information keeps track of doctors moving in and out of Canada. When emigration spiked, 400-500 doctors were leaving Canada for the United States in a year. There are more than 800,000 physicians in the US right now, so I'm skeptical that every doctor who claims to know one of these émigré's actually does.

But it turns out that in 2003, net emigration became net immigration into Canada. Let me say that again. More doctors were moving into Canada than were moving out. 

 Myth 2 (3:58)

Two: Canadians flock to the United States to get care. Many people in the United States believe that people in Canada, frustrated by wait times and rationing, come to the United States for care. These are almost always anecdotal stories and you should know by now how much stock I put in anecdotes. As always, when we can, we should turn to evidence and research.

And on this topic, it does exist. The most comprehensive work I've seen on this topic was published in a manuscript in the peer reviewed journal "Health Affairs". That study looked at how Canadians crossed the border for care, and the authors used a number of different methods to try and answer the question.

First, they surveyed United States border facilities, in Michigan, New York, and Washington. It makes sense that Canadians crossing the border for care would favor sites close by, right? It turns out that about 80% of such facilities saw fewer than one Canadian per month. About 40% saw none in the prior year. And when looking at the reasons for visits, more than 80% were emergencies or urgent visits. In other words, tourists who had to go to the emergency room for a broken leg or something. Only about 19% of those already few visits were for elective purposes.

Next, they surveyed America's best hospitals, because if Canadians were gonna travel for care, they'd be more likely to go to the most well-known and highest quality facilities, right? Only one of the surveyed hospitals saw more than 60 Canadians in one year. And again, that included both emergencies and elective care.

Finally, they examined data from the 1800 Canadians who participated in the national population health survey. In the previous year, only 90 of those 1800 Canadians had received care in the United States. Only 20 of them had done so electively. 

Look, I'm not denying that some people with means might come to the United States for care. If I needed a heart-lung transplant there's no place I'd rather be. But for the vast, vast majority of people, that's not happening. You shouldn't use the anecdote describing these things at a population level. This study showed three different methodologies, all with solid rationales behind them, all showing that this meme is mostly apocryphal. Maybe that's why the manuscript was titled "Phantoms in the Snow".

 Myth 3 (6:00)

Three: Canada has longer wait times because they're a single payer system. When people wanna demonize single payer systems like Canada, they always wind up going after rationing, and more often than you'd think, they talk about things like hip replacements or cataract surgeries. Stories about rationing aren't true. Canadian doctors don't deny hip replacements to the elderly. But there's more.

Do you know who gets most of the hip replacements in the United States? The elderly! Do you know who pays for care for the elderly in the United States? Medicare. Do you know what Medicare is? A single payer system.

Canada isn't some dictatorship. They aren't oppressed. In 1966, the democratically elected government enacted their single payer system. Since then, as a country, they've made a conscious decision to hold down spending. One of the ways they do that is by limiting supply, mostly for elective things, which can create wait times. Their outcomes are otherwise comparable to ours. Please understand: the wait times can be overcome! They could spend more! They don't want to. We can choose to dislike wait times in principle, but they're a by-product of Canada's choice to be fiscally conservative. They chose this.

Those in the United States who are concerned about healthcare spending and what it means to the economy might respect that course of action, but instead, we attack. That's our problem, not theirs.